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HomeMy WebLinkAboutBLDP-21-000704 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK kOs CITY YARMOUTH MA DATE 8/13/20 PERMIT# BLDP-21-000704 JOBSITE ADDRESS 10 LILAC LN OWNER'S NAME MAXWELL RICHARD B P OWNER ADDRESS MAXWELL LEILA R 10 LILAC LN YARMOUTH PORT,MA 02675-1559 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ID RESIDENTIAL m PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT 0 PLANS SUBMITTED: YES NO E1 FIXTURES 1 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/OIUSAND 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 WATER PIPING OTHER 1 OTHER DESCRIPTION:gas boiler INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES III NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m 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. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicator 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 Ralph Giangregorio LICENSE g839 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RALPH J GIANGREGORIO ADDRESS 188 Route 28 CITY Dennis Port STATE MA ZIP 102639 TEL FAX I CELL 1 EMAIL office@3gsplumbing.net • ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY yH�'rr�vil�}�v �l MA DATE PERMIT#h0/2,-4/-07.2.7G JO8SITE ADDRESS !Z) L! /9 c LA.) ' OWNER'S NAME 'd1(i Qb fl/'r W Fl/ OWNER ADDRESS ID At hi �,rti / 'Po f T TEL SO 'r Y!c sd 2) FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL Q/ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:127 PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z 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 4 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 WATER PIPING OTHER GA. kt hQ J INSURANCE COVERAGE: I have a current Iiabilit'Linsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY INSURANCE POUCY ❑ 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 wort:and Installations performed under the permit issued for this application will be in piiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME h.;.leh i' rs,c), � r' LICENSE# .13C? StGNA RE MPE1 JP❑ CORPORATION®#?fieTv C. PARTNERSHIP❑# LLC❑# COMPANY NAME 2:.S Plu,birro Heck ADDRESS / . A.i cf CITY neon,S Part STATE IV4� ZIP C1263 TEL FAXi`sl1i fo451 CELL EMAIL l . ►112f"