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HomeMy WebLinkAboutBLDP-22-002616 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =_==.;T= CITY YARMOUTH MA DATE 11/5/21 PERMIT# BLDP-22-002616 _ t JOBSITE ADDRESS 54 WOOD RD OWNERS NAME GARDINER WILLIAM D P OWNER ADDRESS GARDINER JOYCE 45 BOARDMAN AVE MELROSE,MA 02176 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT _CLEARLY NEW:ID RENOVATION:ElREPLACEMENT:© PLANS SUBMITTED: YES El NO El FIXTIIRFS-1 FLOORS-+ _RSM 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 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❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0 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 at 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 at plumbing work and installations performed under the permit issued far this application will be in compliance with at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Albert Cassano LICENSEIA015 SIGNATURE MP ©' JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Cape Cod Mechanical Systems,Inc. ADDRESS 8 Fruean Way CITY South Yarmouth STATE MA ZIP 02664 TEL 5083947501 FAX CELL 5087769536 EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE 0 0 nrnamtv FEES$ PERMIT# PLAN REVIEW NOTES