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Home My WebLink AboutBLDP&G-17-001376 , MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK = CITY W.YARMOUTH MA DATE 4 09-02-2016 ra PERMIT kK� �`u��3_ JOBSITE ADDRESS 19 SACHEM PATH 1 OWNER'S NAME EMIY GLAMPIETRO OWNER ADDRESS Same TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL`_T4 EDUCATIONAL ,_, RESIDENTIAL:: PRINT CLEARLY NEW:'„,„,„,1 RENOVATION: REPLACEMENT:[' PLANS SUBMITTED: YES NO / FIXTURES-1 FLOOR-+ BSM 1 2 3 4 5 6 I 7 8 9 10 11 12 13 14 BATHTUB ..: is ,. :' ......e ,_ ..�:;... CROSS CONNECTION DEVICE " - •- , • DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/Oft/SAND SYSTEM i DEDICATED GREASE SYSTEM i,,, , , 1 i, DEDICATED GRAY WATER SYSTEM i DEDICATED WATER RECYCLE SYSTEM 1 DISHWASHER r ..: _ DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN •F. ` INTERCEPTOR(INTERIOR) = ' KITCHEN SINK ,. . . 3,...:...__ LAVATORY _ „ ROOF DRAIN SHOWER STALL I al SERVICE/MOP SINK — TOILET E -. �� , Mt iJRINAI WASHING MACHINE CONNECTION a.. WATER HEATER ALL TYPES 1 l , -, ' WATER PIPING 11 OTHER i BACK FLOW 1 j� l' 9 ;aJaaa .zee ....L.— Vfj t l 1' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES% NO `._ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY U OTHER TYPE OF INDEMNITY 1I BOND 'µ 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. I' -- ..—___ CHECK ONE ONLY: OWNER AGENT i_, I _ 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. 11/1( d ✓0 PLUMBER'S NAME LFrank W.Roderick LICENSE# i 7794 SIGNATURE MP Li 1 JP CORPORATION # 1762-C PARTNERSHIP, #I— r- COMPANY NAME Rust 's Inc d-__. I y �ADDRESS 222_Mid-Tech Drive I CITY 1 West Yarmouth STATE( MA ZIP 102673 TEL � ,..., ,.�z_. 508-775-1303 FAX 508-771 9310 CELL EMAIL SELW000@RUSTYSINC COM MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK I tN-- r/. CITY W.YARMOUTH MA DATE'09-06-2016 PERMIT'# ' ' , '- 1574.- a JOBSITE ADDRESS 19 SACHEM PATH OWNER'S NAME EMILY GLAMPIETRO GOWNER ADDRESS Same TEL 508-813-5600 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: _ REPLACEMENT: i PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS-0 BSM 1 r 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 _GENERA_TOR GRILLE —_ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN -- ------� POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT ,ES, T T UNIT HEATER --- — I. UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE 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 'Thereby 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. n //.__ //// PLUMBER-GASFITTER NAME Frank Roderick 6nk /gyp .• LICENSE# 7794 SIGNATURE MP / MGF JP JGF LPG! CORPORATION i # 1762-C PARTNERSHIP # LLC # COMPANY NAME: Rusty's Inc. ADDRESS 222 Mid-Tech Drive CITY West Yarmouth STATE MA ZIP 02673 TEL 508-775-1303 FAX 508-771-9310 CELL EMAIL SELWOOD@RUSTYSINC.COM