Loading...
HomeMy WebLinkAboutBLDP&G-22-006878 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK . r CITY YARMOUTH MA DATE 5/27/22 I PERMIT# BLDP-22-006878 I}c JOBSITE ADDRESS 12 NORTH RD OWNERS NAME ISUMNER DANA S P OWNER ADDRESS ISUMNER NICOLE S 12 NORTH RD WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL 12 PRINT El CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES El NO FIXTIIRFS Fl OORS—. RAM 1 2 3 4 5 6 7 8 9 10 11 12 '3 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 0 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 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 MA SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RUSTYS INC ADDRESS 1222 Mid Tech Dr CITY West Yarmouth STATE MA I ZIP 102673 TEL 5087751303 FAX 1 1 CELL 1 EMAIL 1 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 GAS FITTING WORK -kdn__;r CITY YARMOUTH MA DATE May 27,2022 PERMIT#bz„ BLDP-22-006878 I ' JOBSITE ADDRESS 12 NORTH RD OWNERS NAME SUMNER DANA S G OWNER ADDRESS SUMNER NICOLE S 12 NORTH RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL Q 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 1 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY 0 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-GASFITTER NAME MICHAEL HANSEN LICENSE# MA SIGNATURE MP❑ MGF 0 JP❑ JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RUSTYS INC ADDRESS. 222 Mid Tech Dr, CITY West Yarmouth STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S310N M3IA32i NV-Id #1I W213d $:33d El 1I11d3d 3Hl SY S3AW3S NOIiV3llda SRL oN S8A S310N N01103dSNI 1VNI3 NINO 3Sf1?10103dSNI 2103 30Vd SIHI S310N NO1103dSNI SVO HOflO J