HomeMy WebLinkAboutBLDP&G-16-0066487 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�s � CITY W Yarmouth MA DATE 5/27/16 PERMIT#/ /J9 V 9 7
JOBSITE ADDRESS 18 Lewis Bay Rd -I OWNER'S NAME Comite
1
OWNER ADDRESS 18 Lewis Bay Rd TEL (941)979-7194 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Lfjj RESIDENTIAL
PRINT
CLEARLY NEW:® RENOVATION: REPLACEMENT:Li PLANS SUBMITTED: YES NO
FIXTURES 1 FLOOR— 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/OIUSAND 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
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
WATER PIPING
OTHER
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 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 „,„,a
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 t e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c ance with all P i nt ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME i James Carabitses 'LICENSE# 11156 �-� SIGNATURE
MP JP CORPORATION Q# 3759 PARTNERSHIP R# LLC D#
COMPANY NAME ARS/Heating&NC Services I 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 VK Yarmouth _ ' MA DATE 5/27/16 PERN|T# 6 47
JOB8|TEADDRESS 18Lew�BovRd ---- OWNER'S Comho
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� n� DVVNERAODRESS Comite TEL 194 FAX |
TYPE OR
PRINT COMMERCIAL EDUCATIONAL ] RESIDENTIAL�i
CLEARLY
NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES_ NO
APPLIANCES 1 FLOORS— oam 1 2 3 4 o 8 r 8 8 10 11 o 13 14 '
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLAT0R
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
OTHER
|
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INSURANCE COVERAGE
|have u current liability insurance policy ux its substantial equivalent which meets the requirements ofMGL 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 _J BOND �_]
OWNER'S INSURANCE WAIVER:|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 _J AGENT _J
SIGNATURE 0F OWNER ORAGENT
|hereby certify that all m the details and information|have submitted vr entered regarding mio ,myknowledge
and that m m installations th
e fo
r vwn application n���
m en�o�|s|ono,mo
maanaohu»��nm�p|ummnUCode and ow�e,142mmoaenom|Laws.
PLUMBER,GASF|TTERNAME JomooCambitoox | L|CENSE# 111S8 |- / S|GNATURE
MP M8F ] JP _] JGF | LPG| _] CORPORATION -1# PARTNERSHIP | LLC _]#
COMPANY NAME: ARS/HaaUn &AJC'Services
ADDRESS 30OMon�vS -�
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CITY VV]3hdqo�u�r STATE 'ZIP U237Q /TEL _�U8�0V�025
FAX 5085881050 CELL EMAIL
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