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HomeMy WebLinkAboutBLDP&G-21-001107 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK C,i Y YARMOUTH MA DATE 9/2/20 PERMIT# BLDP-21-001107 -s° - JOBSITE ADDRESS 9 EMBASSY LN OWNER'S NAME VAILLANCOURT CHARLES J P OWNER ADDRESS VAILLANCOURT SHARON D 349 PLAIN ST MILLIS,MA 02054 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:El 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(INTER OR) 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND El 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. PLUMBERS NAME Albert Cassano LICENSE 9015 SIGNATURE MP ❑ JP 0 CORPORATION ❑# I PARTNERSHIP ❑# LLC ❑# COMPANY NAME [ ADDRESS 8 Fruean Way CITY South Yarmouth STATE MA I ZIP 02664 TEL FAX 7 CELL 5087769536 7 EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ FEES$ PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ► 5 CITY YARMOUTH MA DATE September 02, 202 PERMIT# BLDP-21-001107 JOBSITE ADDRESS 9 EMBASSY LN OWNER'S NAME VAILLANCOURT CHARLES J G OWNER ADDRESS VAILLANCOURT SHARON D 349 PLAIN ST MILLIS MA 02054 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 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 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR GRILLE INFRARED HEATER _ LABORATORY COCKS ► 4 MAKEUP AIR UNIT OVEN POOL HEATER ROOM l SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER r F 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 OF INDEMNITY ID 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 Albert Cassano LICENSE # 9015 SIGNATURE MP © MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION El # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: [ ADDRESS. 8 Fruean Way, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX ] CELL 5087769536 EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIOIhNOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE:$ PERMIT# PLAN REVIEW NOTES