HomeMy WebLinkAboutBLDP&G-23-004765 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
' CITY YARMOUTH MA DATE 2/28/23 PERMIT# BLDP-23-004765
.ai
JOBSITE ADDRESS 67 ELDRIDGE RD OWNERS NAME NICKERSON CELESTA P TR
P OWNER ADDRESS BASS RIVER REALTY TRUST 33 HILLTOP RD WELLESLEY,MA 02161 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES NO 0
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 James Pazakis LICENSE lit-15030-M SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME CM PAZAKIS, INC. ADDRESS 447 Old Chatham Road
CITY South Dennis STATE MA —I ZIP 02660 TEL 5083853677
FAX 7 CELL —1 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
r ,_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r CITY YARMOUTH MA DATE February 28, 2023 PERMIT#
BLDP-23-004765
str
---,-1-L: JOBSITE ADDRESS 67 ELDRIDGE RD OWNER'S NAME NICKERSON CELESTA P TR
G OWNER ADDRESS BASS RIVER REALTY TRUST 33 HILLTOP RD WELLESLEY MA 02161 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: El PLANS SUBMITTED: YES ❑ NO ❑
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
1
GENERATOR
•
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER ,
ROOM 1 SPACE HEATE R
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 El
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER 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-GASFITTER NAME James Pazakis LICENSE # PL-15030-M
SIGNATURE
MP 0 MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION El # PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME: Ef.vIPAZAKIS, INC. ADDRESS. 447 Old Chatham Road,
CITY South Dennis STATE MA ZIP 02660 TEL 5083853677
FAX } CELL EMAIL
SOUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE:$ PERMIT#
PLAN REVIEW NOTES