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HomeMy WebLinkAboutBLDP-21-000692 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i*s, CITY YARMOUTH MA DATE 8I13I20 PERMIT# BLDP-21-000692 JOBSITE ADDRESS 17 CORPORATION RD OWNER'S NAME SHELBY HOLDINGS P OWNER ADDRESS 59 OLD STAGE ROAD CENTERVILLE 02632 TEL 1 TYPE OR OCCUPANCY TYPE COMMERCIAL© RESIDENTIAL ❑ PRINT CLEARLY NEW:m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES© NO❑ FIXTURES 1 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 5 INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 3 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK 1 TOILET 3 URINAL WASHING MACHINE CONNECTION WATER HEATER 2 WATER PIPING 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 0 NO 0 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❑ 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 CARL RIEDELL LICENSE Massachusetts SIGNATURE MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME CARL F.RIEDELL&SON INC. ADDRESS 178 SCUDDER ROAD CITY OSTERVILLE STATE MA ZIP 02655 TEL 5084285124 FAX CELL EMAIL <3z69—o26/- 5ao7 ROUGH PLUMBING INSPECTIONTI NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES f G l�,y�S SP U"` //2/Z 4 ZO Yes No THIS APPLICATION SERVE AS THE PERMIT FEES$ PERMIT O/I.FI r 5 PLAN REVIEW NOTES Ok !o//G/xaz.o Gp fVL£!) ✓'LN 7 rG/r- ZelAik ail sr) 2( Ct el/9 f ZOZD 9'31