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Home My WebLink AboutBLDP-23-005967 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/27/23 PERMIT# BLDP-23-005967 _..L= JOBSITE ADDRESS 5 PEREGRINE LN OWNER'S NAME CRIVELLI ANDREW H P OWNER ADDRESS CRIVELLI JANICE G 12 BOULDER BROOK RD EAST SANDWICH,MA 02537 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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❑ NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 Brian Cameron LICENSE 16198 SIGNATURE MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME SEASIDE GAS SERVICE INC. ADDRESS 67 HELMSMAN DRIVE CITY YARMOUTH PORT STATE MA ZIP 02675-0000 TEL FAX CELL EMAIL seasidegas@comcast.net ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTE Yes No THIS APPLICATION SERVE AS THE ❑ 0 FEES$ PERMIT# PLAN REVIEW NOTES �,_ . ,:�::, I «� i ` iACHUSSTTS UNIFORM t; s ' _ ... .w�,.�• ._� APPLICATION FOR A PERMIT 7• 5 CIT rIT yo e -_--_.._.M,.. ... PERFORM , 42 DATE M µ _ , Jess! i. 4 / P4 LESS ��7 - B ILDf DEPq .I E ! - i # �� 425?—: �J OWNER'S NAME_ZatCnfjds.z_____ TYPE OR T T' E OCCUPANCY TYPE CO►f .---- TEL $.-Q..A FAX I5q. T IERCIAL — j EDUCATIONAL ----- CLEARL I NEW: RESIDENTIAL ------ �I+IO�ATIflN: 0 RE PLACEMENT: is-d 0 NO 0 FIXTURES 1 FLOOR-- PLANS SUBMITTED: YES BATHTUB mai MallIMMIEll CROSS CONNECTION DEVICE -----±-'''-- -M—M- ' . 11111 DEDICATED SPECIAL WASTE SY.STEIVI DEDICATED fiAS1017SAND SYSTEI` ra DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 1111 DEDICATED WATER.RECYCLE SY 'l I �� DISHWASHER DRINKING FOTAIN -T--.---• .-j UIL . . ''-' ----lila. FOOD DISPOSER imam FLOOR !AREA DRAIN INTERCEPTOR (INTERIOR) . KITCHEN SINK ---------......--1--------- -- ---------- LAVATORY --..__ __. - �.__ ROOFDRAIN ._.. ..�. -_........_�,.....�.., ......�,._.._,,..,._..-.._._...�. __�. .. __•._..,......, —_�—.- ..�-_.._._�,.___ - .._...�. SHOWER STALL _....-._. .... ._.- _ .. ..,._._.w...,.._.. .-�. � , _� r• _ .._ SECE It flP SINK __� RVI — _ URINAL -.. WASHING MACHINE CONNECTION WATER HEATER ALL TYPES : 1 WATER PIPING OTHEI: -__ _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142_ YES 0 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Seaside policy LIABILITY INSURANCE POLIC`t adOTHER TYPE OF INDEMNITY ❑ BOND 0 Brian is veep plumber eer and active employee 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 tint my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT D SIGNATURE OF CURER OR AGENT hereby certify that ail of the details any: information I have submitted or entered regarding this appfieat on are true aid ace . the. t o . y knowledge - and that all plumbing work and installati:ns performed under the permit issued for this application will be in complian 1rr :- , i bra f t Massachusetts State Plumbing Code ar i Chapter 142 of the General Laws. �;,,:�F "�; .' 18198-PLAA r PLUMBER'S NAME Brian Cameron �E LICENSE # 28909-PL-.� S�'GNATLIRE MP 2 JP 0 CORPORA-ION [i] # 3727' _ PARTNERSHIP ❑ # ----_—__-- LLC 0 # __— COMPANY NAIviE Seaside Gas Serice, Inc ADDRESS 67 Helmsman Dr CITY Yarmouth Port STATE MA ZIP 02675 TEL Kevin Cell 508-400-0943 OwnFAX CELL 508 400 0943 EMAIL BCameron@seasidegasse ac.ceol peratar - Seaside gas PLEASE MAIL BACK TO SEASIDE GAS/HELMSMAN ADDRESS