HomeMy WebLinkAboutBLDP-22-005309 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 3/23122 PERMIT# BLDP-22-005309
JOBSITE ADDRESS 42 LOOKOUT RD OWNERS NAME KELLPETE REALTY TRUST
P OWNER ADDRESS CIO PETER DOHERTY 10 GLAD VALLEY RD BILLERICA,MA 01821 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL al
PRINT
CLEARLY NEW:El RENOVATION:E REPLACEMENT:El PLANS SUBMITTED: YES❑ NO El
FIXTURES 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 4
ROOF DRAIN
SHOWER STALL 2
SERVICE/MOP SINK
TOILET 2
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER
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❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE 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'S NAME Charles Delvecchio LICENSE 16269 SIGNATURE
MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME CHARLES M DELVECCHIO ADDRESS PO BOX 719
CITY FORESTDALE STATE MA ZIP 026440702 TEL
FAX CELL EMAIL none
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
APPLICATiOiN
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Y'• CITY 1 Vo-n---Ircil-ft-rort--- ! MA DATE i�-2 - 2? _ ;PERMIT# 2?- 5 3a
JOBSITE ADDRESS 1 L--R 7 Lc ou7t rZ _ ; OWNER'S NAME; O€
Y
OWNER ADDRESS I TELL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL '. ! RESIDENTIAL 137
PRINT �/
CLEARLY NEW:0 RENOVATION:1Y; REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOE
FIXTURES Z FLOOR— 8SM 1 I 2 I 3 l 4 ; 5 6 7 1 8 9 1 10 ii 1 12 I 13 4 14
BATHTUB ; i I I ; I
:ROSS CONNECTION DEVICE I I I ; f
DEDICATED SPECIAL WASTE SYSTEM 1 i
)EDICATED GAS1011JSAND SYSTEM
)EDICATED GREASE SYSTEM ; I I
)EDICATED GRAY WATER SYSTEM '
)EDICATED WATER RECYCLE SYSTEM _ ! _ ' I I '
)ISHWASHER i I 1 I
IRINKING FOUNTAIN !_ I L
OOD DISPOSER i I I i I i
LOOR 1 AREA DRAIN I i z 1 I
ITERCEPTOR(INTERIOR) I I I I j
ITCHEN SINK 1 I I I I
\VATORY 4 ! i I ,
DOFDRAIN I I _ KEC_EIv !
TOWER STALL _ J I _ _ _ l
:RVICE I MOP SINK _ i 1 ' ! I - 21 l
)ILET a i I I i �
ilNAL "!
ASHING MACHINE CONNECTION J - BU l";,sre+ +11LA C r r f
! -9,
VIER HEATER ALL TYPES I j
\TER PIPING l 1 1 j
'HER 1 I i 1 I i
I' 1 + I
I I I l I _
- - I ! _ _ I
INSURANCE COVERAGE:
we a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO E
'OU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑
NER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
;sachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY -OWNER ❑ AGENT E
SIGNATURE OF OWNER OR AGENT J
eby certify that all of the details and information. "ave suumitted or eme'e:regarding this application are truOnd : to the best of my knowledge
that all plumbing work and instatiations performed Linder the permit issues for this application will be in comp1ianc:� -• Pertinent provisip`pfshe
3echusetts State Plumbing Code and C ter tq2 of the General Laws. i
41BER'SNAME 6 (L LICE-NSE# 13207 SIGNATURE
VJP CORPORATION[ #, PARTNERSHIP❑# ILLC❑#
?ANY NAME I Gtct es e+ H' ADDRESS; p )( -7c,
-j. n STATE 1 .1 c ZIP I J7,(-4 t-( I TEL c `T7—e I!,? 1
j CELL I rZ {EMAIL j ,I
20
+
S APPLICATION SERVES AS THE PERMIT YES NO FEE:$
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