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HomeMy WebLinkAboutBLDP-22-006280 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK f; CITY YARMOUTH MA DATE 5/2/22 PERMIT# BLDP-22-006280 AT) JOBSITE ADDRESS 16 WIDGEON LN OWNER'S NAME Brian Mangoudis P OWNER ADDRESS SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES • FLOORS-4 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 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER 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 Richard Nagle LICENSE 1A756 SIGNATURE MP ❑ JP ❑ CORPORATION D# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RICHARD F NAGLE ADDRESS 12 Funn Pond Rd CITY South Dennis STATE MA ZIP 026601906 TEL FAX CELL 5083140406 EMAIL rfnagle1960@gmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El ❑ FEES$ PERMIT# PLAN REVIEW NOTES • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =-1_ CITY 9 Ci d MA DATE 7-- 2._ 2.-- PERMIT# 2Z Z- co - JOBSITE ADDRESS OWNER'S NAME 1\40-uicy i)d 1 S / Di-<<�,, POWNER ADDRESS 1(0 L)I h J tea..r3 Lin-_ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL©/ PRINT CLEARLY NEW: ❑ RENOVATION:-'REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1. FLOOR-4 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/OIUSAND SYSTEM — DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER • DRINKING FOUNTAIN J FOOD DISPOSER FLOOR!AREA DRAIN ' INTERCEPTOR(INTERIOR) - - KITCHEN SINK - • LAVATORY ' / ROOF DRAIN T SHOWER STALL I ' SERVICE I MOP SINK TOILET / - URINAL . j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY [Cl/"-- 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. T CHECK ONE ONLY: OWNER 0 AGENT ❑ Z. SIGNATURE OF OWNER OR AGENT L',1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accuiate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will co pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' PLUMBER'S NAME LICENSE# /0 7T 6. IGNATURE MP 10 JP El CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME i 1— °`�a5}e Pi Uwt b 1 ruc ADDRESS 1 .2— —12 c' (N Ponct n`-12 CITY 1 '(i)1("\ I S STATE I144- ZIP #2 G///11 TEL cok--3g 3-- 2/7 Z- FAX CELL 50r`3/y -o y06 EMAIL 'Q >` NO``j)e )16 C- rii 7 --Goy ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# _ PLAN REVIEW NOTES