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HomeMy WebLinkAboutBLDP&G-22-798 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY w/ MA DATE i -i( =L( PERMIT# ZZ --15( JOBSITE ADDRESS 2y Cw/e- OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL PRINT / CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:LE PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 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/OIL/SAND SYSTEM —� DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM —a DEDICATED WATER RECYCLE SYSTEM - -DISHWASHER DRINKING FOUNTAIN - - —J FOOD DISPOSER ---� FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY • --—� ROOF DRAIN - - SHOWER STALL 1 SERVICE/MOP SINK _T_ __ TOILET URINAL 1t) WASHING MACHINE CONNECTION �►tl L WATER HEATER ALL TYPES WATER PIPING Bull O NG DEPAR'MEN OTHER - ` ---  INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ID—NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY IiI/ 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT LILI 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 i mpliance wi al Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .,.. PLUMBER'S NAME PQ�l !(<rl) LICENSE#(/(c8�. SIGNATURE MP i JP 0 / '11 CORPORATION❑# PARTNERSHIP❑.# LLLC❑# COMPANY NAME /4/(+ P# r, ADDRESS 77 ��k �p `/ CITY I(/''f//514 STATE Pict ZIP !� o t4. TEL' °3/ v Z r FAX / CELL EMAIL U/, 4 f o ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK E10$ CITY YARMOUTH MA DATE August 11, 2021 PERMIT# BLDP-22-000798 JOBSITE ADDRESS L4 WOODBINE AVE OWNER'S NAME barbara pooch G OWNER ADDRESS [ jWOODBINE AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS BSM 1 2 3 4 5 i 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 ❑ 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 Paul Kelly LICENSE # 11689 SIGNATURE MP © MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: Paul J Kelly ADDRESS. 70 SHOREWOOD DR, CITY MASHPEE STATE MA ZIP 026492817 TEL I FAX CELL EMAIL L S310N M3IA3a NVId # $:33d ❑ ❑ 111*Ed 3H1 SV SAS NOIlV011ddV SIH1 ON Se), S310N N01103dSNI 1VNId AINO 3Sf1210103dSNI a0d 30Vd SIHl S310N N01103dSNI SVO HOflOa Id1ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 43 4ro „ CITY i`. ;.•t-9:.-'4 MA DATE 4 ' PERMIT# ZZ- — 7 k f JOBSITE ADDRESS ?`f 1�•'�•' �c . �>r OWNER'S NAME OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ _ APPLIANCES FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 71 BOILER ----� BOOSTER CONVERSION BURNER, I i COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYC)LATOR FURNACE GENERATOR - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER --r ROOF TOP UNIT R E C El V- E D- TEST UNIT HEATERAUG 10 UNVENTED ROOM HEATER V . WATER HEATER -•— OTHER 6UILDtVC DtOPART ENT INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E11 ❑ 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 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 Lt.L Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1-)I PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP i4GF❑ JP❑1 JGF❑ LPGI ❑ CORPORATION IDfF PARTNERSHIP❑It LLC❑# COMPANY NAME ` ADDRESS 70 jLl t Li-4'44 1 CITY STATE nA ZIP 0 iZ G Lf S�TEL $' D'a. FAX CELL EMAIL a'✓I ige-t r 17 go. CA ,. s ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 'des No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT# PLAN REVIEW NOTES