HomeMy WebLinkAboutBLDP-22-002966 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1;7CITY YARMOUTH MA DATE 11/22/21 PERMIT# BLDP-22-002966
I� JOBSITE ADDRESS 8 YACHT AVE OWNER'S NAME Sandra Connoly
P OWNER ADDRESS MA01453-1770 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO❑
FIXTURFS FLOORS—, RSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
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 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
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 El NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND El
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 Charles Delvecchio LICENSE VA269 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
L/
COMPANY NAME CHARLES M DELVECCHIO ADDRESS IPO BOX 719
CITY FORESTDALE STATE MA ZIP 026440702 I TEL I
FAX CELL EMAIL none
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
APPLICATION#
c.. .11.ASS.2.5, 'e.:-_. : �,I:FORM AL;: ; : FOR.--‘, .i'EM: L M- PERFORM PLUME WORK
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;' i CITY I ° ��i3c'Ir�a.r '- I MA DATE; ' --) --2,1 ;PERMIT# Z'Z - Z 6
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LJI�I JOBSITE ADDRESS 1 g \/*c - ; OWNER'S NAME; S f- CONNnly
—" : 00 p OWNER ADDRESS I TEL! jFA,:I
LL4 , — ;-�
5YPE-DR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL !7 RESIDENTIAL L�
GPRII#
W LEARL M NEW:E RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOE
L__,_...__ m T '
Ct
i, FIXTIIRFR'1 FLOOR-' 8SM 1 1 2 ; 3 1 4 1 5 I 6 7 1_ 8 9 10 11 12 13 I 14
BATHTUB 1 j i I I
:ROSS CONNECTION DEVICE j I j j
)EDICATED SPECIAL WASTE SYSTEM ; I i
)EDICATED GAS/OIL/SAND SYSTEM _ i _ ! ! I I
)EDICATED GREASE SYSTEM I 1
)EDICATED GRAY WATER SYSTEM ' ! 4 I ! i
)EDICATED WATER RECYCLE SYSTEM I ! I j
IISHWASHER I
IRINKING FOUNTAIN i
OOD DISPOSER I ! 1 I ; _ I I
LOOR/AREA DRAIN I I
ITERCEPTOR(INTERIOR) I
� -
c
ITCHEN SINK I I j I
WATORY j i 1
DOF DRAIN _
-lOWER STALL
_RVICE/MOP SINK I
)ILET 11 I I i
- F 1
•
1INAL _ I
4SHING MACHINE CONNECTION _
;TER HEATER ALL TYPES j
\TER PIPING
HER I
. I i
1 1
INSURANCE COVERAGE:
we a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO E
'OU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I
I
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BONO E
NER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
;sachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY' OWNER E AGENT ❑
SIGNATURE OF OWNER OR AGENT '. I
eby certify that all of the details and information I have submitted or entered regarding this application are truOnd = to the best of my knowledge
that all plumbing work and installations performed under the permit issued for this application will b Ltb
e in compllanc=. Pertinent provision ae
sachusetts State Plumbing Code and C ter 1�j2 of the General Laws. r`r/
MBER'S NAME 0h-C-�y1t Cr, \lG I LICENSE#I l.3-2,6c, I SIGNATURE
1 JP CORPORATION❑#1 JPARTNERSHIPE#I ILLC❑#I I
?ANY NAMEI C. -f E et+ 1+ I ADDRESS I pc") Tjx
i n !STATE 17,77 ZIP 1 E.)Z&q L( I TEL 1 172-6(I,?I
1 CELL;Spa-'Z2 EMAIL I I+
S APPLICATION SERVES AS THE PERMIT YES NO
FEE:$