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HomeMy WebLinkAboutBLDP&G-22-00388 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Ragrtt� , CITY 'YARMOUTH MA DATE I7121121 I PERMIT# BLDP-22-000388 q =j ` , JOBSITE ADDRESS 110 FORTUNE RD OWNER'S NAME JOY SHANNON M tit. OWNER ADDRESS 10 FORTUNE RD YARMOUTH PORT,MA 02675 I TEL P TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO FIXTURFS • 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 0 NO 0 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. I I PLUMBER'S NAME (Kevin Decoteau LICENSE116532-m SIGNATURE MP 10 JP ElCORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# COMPANY NAME I ADDRESS 138 Powhatan Rd CITY (South Yarmouth I STATE (MA I ZIP (02664 TEL I FAX I I CELL I —1 EMAIL ( ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE LSE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ 0 FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =fir BLDP-22-000388 _ „ CITY YARMOUTH MA DATE July 21, 2021 PERMIT# JO[3SITE ADDRESS 10 FORTUNE RD OWNER'S NAME JOY SHANNON M G OWNER ADDRESS 10 FORTUNE RD YARMOUTH PORT MA 02675 TEL __. TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEVV: ❑ RENOVATION:❑ REPLACEMENT: 0 PLANS SUBMITTED: YES ❑ NO 0 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 0 NO ❑ IF YOU CHECKED YES, F LEASE 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 pl ambing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massacl'usetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Kevin Decoteau LICENSE# 16532-m SIGNATURE • MP 0 MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: ADDRESS. 38 Powhatan Rd, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX '1 CELL EMAIL S310N M3IA3H NVId #.IV d $ 33d ❑ ❑ 1II1 d 3H1 SY S3AH3S NOI1V3I1ddV SIHl ON saA S31ON NO1103dSNI 1VNId AINO 3sn N0133dSNI NOd 39Vd SIH1 SaLON NO1103dSNI SVO H0f1021