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Home My WebLink AboutBLDP&G-19-000443 ..,�.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK M.tiun! �' _ '' CITY South Yarmouth MA DATE 7/17/18 J PERMIT# /3AVn-M JOBSITE ADDRESS 12 Briar Circle OWNER'S NAME Marylou Deeso OWNER ADDRESS ; Same TEL 508-394-0114 ,FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ? RESIDENTIAL PRINT CLEARLY NEW: n RENOVATION:L REPLACEMENT:�, �, PLANS SUBMITTED: YES > NO! FIXTURES 7 FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ° ®nill CROSS CONNECTION DEVICE i 11111111111.111111111111111111111-1111111® DEDICATED SPECIAL WASTE SYSTEM LLD, �(; DEDICATED GAS/OIL/SAND SYSTEM ®® ® IIIIII DEDICATED GREASE SYSTEM I I, ® 111111111111111101111111 DEDICATED GRAY WATER SYSTEM ELM __®® DEDICATED WATER RECYCLE SYSTEM L — II —® ®_®_MIMI DISHWASHER = _ _ _®___-_® DRINKING FOUNTAIN ( II ', MIN®IIIIIIIIIII®®_®EN FOOD DISPOSER ; -_MI_®®_®®1111. FLOOR/AREA DRAIN [ i NM WWII INTERCEPTOR(INTERIOR) if 111111111111111111111111111 IIIIIIIIIIIIIIIIIIII KITCHEN SINK -I -. i.. . LAVATORY _ Ti11 1 ROOF DRAIN _��tlLL SHOWER STALL -____ i IN SERVICE/MOP SINK ®®��-®� TOILET URINAL r WASHING MACHINE CONNECTION ); �� ®®� MIN WATER HEATER ALL TYPES 1 _ .. WATER PIPING .._ _._ ; � _._ OTHER IL 1 E 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 izi OTHER TYPE OF INDEMNITY £ BOND iI 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. CHECK ONE ONLY: OWNER Ll AGENT ,_ 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. . _,, y //`f__ PLUMBER'S NAME Frank W. Roderick LICENSE# 7794 /'�IYN` SIGNATURE' MP /1 JP Li CORPORATION ril# 1762-C PARTNERSHIP 4, #L.� 1 LC �# ` COMPANY NAME i Rush's Inc. ADDRESS 222 Mid-Tech Drive CITY West Yarmouth STATE 1 MA ZIP F02673 i TEL i 508 775-1303 FAX f 508-771-9310]CELL L - EMAIL mburke@rustysinc.com eta727 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ice' �";�1�i CITY South Yarmouth MA DATE 7/17/18 PERMIT#, ��' ��/t1 1116 tAV JOBSITE ADDRESS 12 Briar Circle OWNER'S NAME Marg Lou t77e. e30 GOWNER ADDRESS .:)ai-✓1 �m µ TEL 508 394 0114 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT ,,. CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO ',_' APPLIANCES 7 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 INSURANCE COVERAGE I have a current Iiability_insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY 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. CHECK ONE ONLY: OWNER AGENT 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. /k 7`i / !PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 SIGNATUREd•�. MP if MGF JP JGF LPG' „j CORPORATION # 1762-C PARTNERSHIP # i LLC # COMPANY NAME: Rusty's A ADDRESS 222 Mid-Tech Drive CITY West Yarmouth STATE MA ZIP 02673 TEL 508-775-1303 FAX 508-771-9310 CELL! EMAIL mburke@rustysinc.com e' 7 2 ?