HomeMy WebLinkAboutBLDP-22-000862 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
i CITY YARMOUTH MA DATE 8/16/21 PERMIT# BLDP-22-000862
i y —
� .:, JOBSITE ADDRESS 1 LEEWARD RUN OWNER'S NAME GIARDINO FREDERICK
P OWNER ADDRESS GIARDINO NANCY L 57 BLAINE ST MALDEN,MA 02148-6203 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO El
FIXTURFS FLOORS— BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM 1
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 1
SERVICE/MOP SINK
TOILET
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❑ NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El 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 Dennis Gagne LICENSE 9804 SIGNATURE
MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME (DENNIS M GAGNE ADDRESS 31 Cherrywood Ln
CITY (Marstons Mills I STATE (MA —I ZIP (026481761 ( TEL
FAX 1 ( CELL I I EMAIL (gagneamg51@aol.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE El ❑
FEES PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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ow. .. CITY � � � MA DATE S 1 ,S .,, -( PERMIT #
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JOBSITE ADDRESS e)s .sue L XjLK 1 OWNER'S NAME 105 e„, �c
OWNER ADDRESS _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR—. 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 SYSTEM
DISHWASHER
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY t s
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
BU1LD1tvi PAR� [1iFh1T
TOILET By �E —
URINAL
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current Iiability_insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 4 NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF 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 wok and installations performed under the permit ssued 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 707 Af4e..e LICENSE # ilY%- '4Y SIGNAT
1� '/ PARTNERSHIP . #� LLC #1
MP JP CORPORATION �'/# 3z3J
COMPANY NAME // �/1i ' / 3W' c ADDRESS , `/ 69/ii,e5.V
---� ZIP zC:75 TEL 72e(-
9 4 rlo 'd 7�r
CITY d.,/fr.!/.7-he%Y 1STATE ,ro:
- - -- EMAIL /Ze /7?�� ( l7G( 'i6 ,
FAX CELL
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