Loading...
HomeMy WebLinkAboutBLDP&G-22-006863 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK it•y, CITY YARMOUTH MA DATE 5/26/22 PERMIT# BLDP-22-006863 JOBSITE ADDRESS 1 HATCH RD OWNERS NAME GESSAY JOHN M P OWNER ADDRESS GESSAY SUSAN A P 0 BOX 963 SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES NO❑ FIXTURFS • FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 , 14 , BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _ KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME mICHAEL hANSEN LICENSE 16906 SIGNATURE MP 0 JP 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Rustys Inc ADDRESS 222 Mid Tech Dr CITY W Yarmouth STATE IMA I ZIP 02673 TEL 5087751303 FAX CELL I EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE 0 ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK G 41„ ra CITY YARMOUTH MA DATE May 26,2022 PERMIT# BLDP-22-006863 JOBSITE ADDRESS 1 HATCH RD OWNER'S NAME GESSAY JOHN M G OWNER ADDRESS GESSAY SUSAN A P 0 BCX 963 SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN • POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST • UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY El BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all cf the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME mICHAEL hANSEN LICENSE# 15906 SIGNATURE MP 0 MGF 0 JP 0 JGF❑ LPG] ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: Rustys Inc ADDRESS. 222 Mid Tech Dr, CITY W Yarmouth STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S31ON MIA Ndld #±IVJ d $ :33d !IV 2d 3H1 SY S3A2i3S NOI1VOIlddy SIHl oN saA S31ON NO1103dSNI IYNId AlNO 3Sfl 10103dSNI 2lOd 30Vd SIHI S310N N01103dSNI SVO HOflOzl