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HomeMy WebLinkAboutBLDP&G-22-004116 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 1/25/22 PERMIT# BLDP-22-004116 JOBSITE ADDRESS 55 OUT OF BOUNDS DR OWNER'S NAME HARRIS JOHN H P OWNER ADDRESS HARRIS JOAN F 55 OUT OF BOUNDS DR SOUTH YARMOUTH,MA 02664 200 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO 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❑ NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© 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 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 Keith Farnham LICENSE 141601 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME (South Shore Heating&Cooling I ADDRESS 57,Whites Path CITY (South Yarmouth STATE IMA I ZIP 102664 TEL 5083986901 FAX 1 I CELL I I EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 25, 2022 PERMIT# BLDP-22-004116 sir { JOBSITE ADDRESS 55 OUT OF BOUNDS DR OWNER'S NAME HARRIS JOHN H -I G OWNER ADDRESS HARRIS JOAN F 55 OUT OF BOUNDS DR SOUTH YARMOUTH MA 02664 200 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: El PLANS SUBMITTED: YES ❑ NO El 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 El 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 Keith Farnham LICENSE # 11601 SIGNATURE MP El MGF 0 JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # Lc ❑ # COMPANY NAME: South Shore Heating & Cooling ADDRESS. 57, Whites Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5083986901 FAX CELL EMAIL S31ON M3IA321 NVId #111%13d $:33d ❑ ❑ 1I141213d 3H1 SV S3A213S NOI1VOIlddV SIHl oN s9A S31ON NO1103dSNI 1VNId A1NO 3Sfl 210103dSNI 210d 39Vd SIH1 S31ON NOI103dSNI SV9 H911021