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HomeMy WebLinkAboutBLDP&G-19-002726 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK South Yarmouth 10/25/18 PERMIT#%7rw/('T -00 o2Z ' —'"�—' MA DATE• CITY JOBSITE ADDRESS 41 Captain Percival Rd,South Yarmouth,MA 02664 OWNERS NAME Scott Adamson POWNER ADDRESS 41 Captain Percival Rd,South Yarmouth,MA 02654 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ NO 0 FIXTURES 7 FLOOR—r ESM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 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 UABILITY 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❑ 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 al nent pro n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME Robert D.Fratus,Jr UCENSE# 11296 MP® JP 0 CORPORATION 0# PARTNERSHIP❑# LLC❑# COMPANY NAME BC Plumbing&Heating ADDRESS PO Box 873 CITY Brewster STATE MA Zip 02631 TEL 508-896-1878-clerical# FAX 508-896-9130 CELL 508-958-1424 EMAIL N/A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _ �fT►{ ; CITY South Yarmouth MA DATE 10/25/18 PERMIT# JOBSITE ADDRESS 41 Captain Percival Rd, South Yarmouth, MA 02664 OWNER'S NAME Scott Adamson OWNER ADDRESS 41 Captain Percival Rd, South Yarmouth,MA 02664 TEL FAX N/A TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑x 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 - outside INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT _ OVEN I POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 _ OTHER INSURANCE COVERAGE I have a current Iiability_insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 2] 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 the st o o dge and that all plumbing work and installations performed under the permit ssued for this application will be in complianriy '' ert. n pro s' oft e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Robert D. Fratus, Jr LICENSE# 11296 SIGNATURE MP❑x MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC ❑# COMPANY NAME BC Plumbing & Heating ADDRESS PO Box 873 CITY Brewster STATE MA ZIP 02631 TEL 508-958-1424 FAX 508-896-9130 CELL 508-958-1424 EMAIL N/A clerical#508-896-1878 a if