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HomeMy WebLinkAboutBLDP&G-22-002031 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK = r_b CITY YARMOUTH MA DATE 10/8/21 PERMIT# BLDP-22-002031 �� - JOBSITE ADDRESS 23 RAYMOND AVE OWNER'S NAME MEDEIROS ERNEST G P OWNER ADDRESS MEDEIROS KERRY A 23 RAYMOND AVE SOUTH YARMOUTH,MA 02664 194 TEL ] TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO FIXTURFS FLOORS-4 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 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 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 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'S NAME r checkoway LICENSE 13417 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# ] COMPANY NAME ADDRESS 11 scargo hill rd CITY DENNIS,MA 02638 STATE MA ZIP 02638 TEL J FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e CITY YARMOUTH MA DATE October 08,2021 PERMIT# BLDP-22-002031 tf JOBSITE ADDRESS 23 RAYMOND AVE OWNER'S NAME MEDEIROS ERNEST G G OWNER ADDRESS MEDEIROS KERRY A 23 RAYMOND AVE SOUTH YARMOUTH MA 02664 194 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES 0 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/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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER 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. 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 r checkoway LICENSE# 13417 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. 11 scarpo hill rd, CITY DENNIS,MA 02638 STATE MA ZIP 02638 TEL FAX CELL EMAIL ShcON M31AR1 NYld #tI1NHl3d $ 33d El El 111A1H3d 3Hl SV S3/\ 13S NOLLVOIlddV SIHI oN seA S310N NOI103dSNI 1VNId A1N0 3Sf O103dSNl 2 0d 3OVd SIHl S31ON NO1103dSNI SVO H9f1021