HomeMy WebLinkAboutBLDP&G-17-03109 - r— . , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
"al— CITY W.Yarmouth MA DATE 11/25/16 PERMIT# OP J7—Gd ✓/Qc(
ti JOBSITE ADDRESS 68 Higgins Crowell Rd OWNERS NAME Anderson
POWNER ADDRESS 68 Higgins Crowell Rd _ TEL (508)335-6704 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ,il EDUCATIONAL RESIDENTIAL .
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: i_ PLANS SUBMITTED: YES NO
FIXTURES-1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 111111
DEDICATED SPECIAL WASTE SYSTEM Mr— _Mil®___®®
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER _____S________ _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
LAVATORY ____®Mill___®�___
ROOF DRAIN _®__® ________
SHOWER STALL ®___®INE ___�
SERVICE/MOP SINK
TOILET 111.11111_—______ _
URINAL ____ _
WASHING MACHINE CONNECTION ___® _
WATER HEATER ALL TYPES 1 _
WATER PIPING ______________ _
OTHER u.w e_ �� �����������
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 0 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
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application a true and accurst hi best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will in co pliance with Pertir/ent provision of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ; (
(ALA-- '----
PLUMBER'S NAME JAMES CARABITSES LICENSE# 11156 SIGNATURE
MP i; JP CORPORATION i # 3759 PARTNERSHIP`_,# i LLCM#
COMPANY NAME ARS HEATING&AC SERVICES ADDRESS 300 MANLEY ST
CITY!W.BRIDGEWATER i STATE MA ZIP 02379 i TEL 508-588-9025
FAX 508-588-1059 CELL EMAIL
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY W.Yarmouth, MA DATE 11/25/2016 PERMIT# d( �V
JOBSITE ADDRESS 68 Higgins Crowell Rod OWNER'S NAME Anderson-68 Higgins Crowell Rd
G
OWNER ADDRESS Anderson-68 Higgins Crowell Rd — TEL (508)335-6704 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES 1 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 Is
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 accurat he besti of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be/th compliance with Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (,
,PLUMBER-GASFITTER NAME JAMES CARABITSES LICENSE# 11156 1 1GNATURE
MP .,,. MGF j JP JGF LPGI CORPORATION � # 3759 PARTNERSHIP # LLC #
COMPANY NAME: ARS HEATING&AC SERVICES ADDRESS 300 MANLEY ST --
CITY W.BRIDGEWATER STATE MA ZIP 02379 TEL 508 588 9025
FAX 508-588-1059 CELL EMAIL