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HomeMy WebLinkAboutBLDP&G-22-003182 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK k:Th3s CITY YARMOUTH MA DATE 12/4/21 PERMIT# BLDP-22-003182 • JOBSITE ADDRESS 31 SIERRA WAY OWNERS NAME DALY JOSEPH F P OWNER ADDRESS DALY CHRISTINE 31 SIERRA WAY WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO 0 FIXTURFS FLOORS—) RSM 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 0 BOND 0 OWNERS 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 1 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 at plumbing work and installations performed under the permit issued for this application we be in compliance with an Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME r peter checkoway LICENSE1A417 SIGNATURE MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 11 scargo hill rd CITY dennis STATE MA ZIP 02638 TEL FAX CELL EMAIL I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES S PERMIT# PLAN REVIEW NOTES .• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK fk,..,tom= BLDP-22-003182 CITY YARMOUTH MA DATE December 04,202' PERMIT# JOBSITE ADDRESS 31 SIERRA WAY OWNER'S NAME DALY JOSEPH F G OWNER ADDRESS DALY CHRISTINE 31 SIERRA WAY WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO©' FIXTURES FLOORS—4 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 © NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER 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. PLUMBER-GASFITTER NAME r peter checkoway LICENSE# 13417 SIGNATURE MP El MGF 0 JP❑ JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 11 scarqo hill rd, CITY dennis STATE MA ZIP 02638 TEL FAX CELL EMAIL S31ON M31A321 NVld #JIW2J3d $:33d ❑ ❑ 11W2l3d 3141 SV SRA213S NOIlv3 lddb SIHl oN sa, S31ON NO1103dSNI IVNId J.lNO 3Sfl 210103dSNI 2IOd 30Vd SIH1 S3ION NO1103dSN1 SVD HOl0H