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HomeMy WebLinkAboutBLDP&G-23-001051 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK uielCITY YARMOUTH lMA DATE 8/26/22 PERMIT# BLDP-23-001051 t�/ JOBSITE ADDRESS 82 CROWELL RD OWNER'S NAME CICCARELLI JOHN F P OWNER ADDRESS CICCARELLI ROSEMARY P 0 BOX 9645 AMHERST,MA 01059 964 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ 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❑ 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 michael maille LICENSE 11355 SIGNATURE MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 48 shore dr CITY dracut STATE MA ZIP 01826 TEL FAX I CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES S PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ii\.,, '+ 6 CITY YARMOUTH MA DATE August 26, 2022 PERMIT # BLDP-23-001051 FIIq /rf JOBSITE ADDRESS 82 CROWELL RD OWNER'S NAME CICCARELLI JOHN F G OWNER ADDRESS CICCARELLI ROSEMARY P 0 BOX 9645 AMHERST MA 01059 964 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: ❑ 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 liabilit' 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 requiremeit. SIGNATURE OF OWNER OR AGENT I hereby certify that all Df 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 michael maille 1 LICENSE # 11355 SIGNATURE MP © MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: ADDRESS. 48 shore dr, CITY dracut STATE MA ZIP 01826 TEL FAX CELL , EMAIL S310N M3IA3b NVId #lIW?J3d $:33d ❑ ❑ 1IV Bd 3H1 SV S3A2f3S NOI1V3IlddV SIHI oN SO) S31ON NOI103dSNI 1VNId ,llNO 3Sfl 210103dSNI HOd 30Vd SIHl S310N NO1103dSNI SVO HOfOH