HomeMy WebLinkAboutBLDP&G-21-001707 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 10/3/20 PERMIT# BLDP-21-001707
111-04 JOBSITE ADDRESS 159 WIANNO RD OWNER'S NAME FALLON JOHN K
P OWNER ADDRESS IFALLON ROSA M 159 WIANNO ROAD YARMOUTH PORT,MA 02675 216 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 111
FIXTURES FLOORS—I 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 NDEMNITY❑ 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'egarding 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 Michael Grillo LICENSE 36651 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME IThonus North PHAC ADDRESS PO Box 14
CITY Yarmouthport STATE MA 7 ZIP 02675 TEL 7745215698
FAX CELL —I EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
.4 CITY YARMOUTH MA DATE 10/3/20 PERMIT # BLDP-21-001707
! wpm ' OWNER'S NAME FALLON JOHN K
!-.717 JOBSITE ADDRESS 159 WIANNO RD
P OWNER ADDRESS FALLON ROSA M 159 WIANNO ROAD YARMOUTH PORT, MA 02675 216 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL D
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO ❑
FIXTURES •.f 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 Plumting Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Michael Grillo LICENSE 13651 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME iThonus North PHAC ADCRESS PO Box 14
CITY Yarmouthport STATE MA 7 ZIP 02675 TEL 7745215698
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑
FEESS PERMITR
PLAN REVIEW NOTES