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HomeMy WebLinkAboutBLDP&G-22-006141 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w,m CITY YARMOUTH MA DATE 4/26122 PERMIT# BLDP-22-006141 FI JOBSITE ADDRESS 184 PAWKANNAWKUT DR OWNER'S NAME GROSSMAN ROBERT S P OWNER ADDRESS GROSSMAN SHEILA 184 PAWKANNAWKUT DR SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES El 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 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 El NO El 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 El 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 James Carabitses LICENSE fA156 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME ARS Boston ADDRESS 300,Manley St. CITY West Bridgewater STATE MA ZIP 02379 TEL 5085889025 FAX CELL I EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k BLDP-22-006141 i CITY 'YARMOUTH MA DATE April 26, 2022 PERMIT# .gyp JOBSITE ADDRESS 184 PAWKANNAWKUT DR OWNER'S NAME GROSSMAN ROBERT S G OWNER ADDRESS GROSSMAN SHEILA 184 PAWKANNAWKUT DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: 0 PLANS SUBMITTED: YES ❑ NO 0 FIXTURES 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 OVEN POOL HEATER ROOM /SPACE HEATER - ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER _ WATER HEATER 1 , 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 0 NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER 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 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-GASFITTER NAME James Carabitses LICENSE# 11156 SIGNATURE MP © MGF ❑ JP ❑ JGF ❑ LPGI 0 CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: ARS Boston ADDRESS. 300, Manley St., CITY West BridgewatEr STATE MA ZIP 02379 TEL ,5085889025 FAX ] CELL EMAIL S310N MJIA3a NVId #1101213d $ 33d ❑ 1IWdOd 3H1 SV SIAa3S NOIlV0IlddV SIH1 oN SeA S310N N01133dSNI IVNId AINO 3Sf1 a0133dSNI a0d 30Vd SIHI S3 LON N01103dSNI SVO HOl0a