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HomeMy WebLinkAboutBLDP&G-18-006262 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK E- CITY YARMOUTH MA DATE May 08, 2018 PERMIT# BLDP-18-006262 r, i'JOBSITE ADDRESS 80 CAPT LOTHROP RD OWNER'S NAME ROLLF GARRIF1 I F_K Ccity-Le Z12,S it.L G OWNER ADDRESS 80 CAPT LOTHROP RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD • 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 El 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 Richard Farrenkopf LICENSE# 33051 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RICHARD R FARRENKOPF ADDRESS 20 HAYWOOD AVE, CITY S YARMOUTH STATE MA ZIP 026641818 TEL FAX CELL 5083603175 EMAIL richardfarrenkopf(a�yahoo.com S31ON NV1d #llWb3d $ 33d 0 ❑iIWH3d 3Hl SV S3/V:I3S NOIlV011ddV SIHI oN saA S31ON NOILO3dSNI 1YNId A1NO 3Sf1 2IO±O3dSNI 2IOd 3OVd SIH1 S31ON NOIL03dSNI SVO HJfO2i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Yarmouth MA DATE 5/8/18 PERMIT# $/; `, - / F ' 0.36:h ;,2. JOBSITE ADDRESS 80 Capt Lothrop 1OWNER'S NAME Claire Driscoll OWNER ADDRESS Same TEL 5087408254 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 7 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 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 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 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 Richard Farrenkopf LICENSE# 33051 NATURE MP MGF JP JGF LPG' CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: R Farrenkopf III P+H I ADDRESS 20 Haywood Ave CITY South Yarmouth STATE Ma ZIP 02664 TEL 5083603175 FAX CELL EMAIL richardfarrenkopf©yahoo.com IMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ik_ CITY YARMOUTH MA DATE 5/8/18 PERMIT# BLDP-18-006262 JOBSITE ADDRESS 80 CAPT LOTHROP RD OWNER'S NAME ROLLF GABRIELLE-K4 Cc,/i C P OWNER ADDRESS 80 CAPT LOTHROP RD SOUTH YARMOUTH, MA 02664 TEL , ?,SC_a.& TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL E] PRINT _CLEARLY NEW: E RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YESE NO E FIXTURES l FLOORS— 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 E IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY❑ BOND E 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 Richard Farrenkopf LICENSE p3051 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RICHARD R FARRENKOPF ADDRESS 20 HAYWOOD AVE CITY S YARMOUTH STATE MA ZIP 026641818 TEL FAX CELL 5083603175 EMAIL richardfarrenkopf@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES, Yes No THIS APPLICATION SERVE AS THE ❑ DC DMIT FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _�� CITY iYarmouth MA DATE i5/8/18 PERMIT# ' 'r JOBSITE ADDRESS 180 Capt Lothrop OWNER'S NAME Claire Driscoll _ , POWNER ADDRESS !Same TELr5087408254 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL J RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NO ,1 FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB n ,� CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ 1 I. 1' 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 ROOF DRAIN - SHOWER STALL if i( SERVICE/MOP SINK TOILET r- _ £. -_ti . URINAL WASHING MACHINE CONNECTION . WATER HEATER ALL TYPES 1 _ , � _ -� WATER PIPING - : : 4it �� ,.�• 3 OTHER ,Li- �( INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i 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 1 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 Richard Farrenkopf LICENSE# 33051 ATURE MP JP(] CORPORATION Ij# !PARTNERSHIP#r LLC # COMPANY NAME R Farrenkopf � III P+H ADDRESS 1 20 Haywood Ave CITY South Yarmouth STATE MA ZIP I2664 TEL 5083603175 FAX i CELL I EMAIL richardfarrenkopf@yahoo.com