HomeMy WebLinkAboutBLDP&G-23-003621 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
9j k CITY YARMOUTH MA DATE 1/4/23 PERMIT# BLDP-23-003621
t.,
- JOBSITE ADDRESS 50 TASMANIA DR OWNER'S NAME GILLIS MARCIA A TR
P OWNER ADDRESS MARCIA A GILLIS LVG TRUST 50 TASMANIA DR YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
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❑ 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 D
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 Mark Moran LICENSE 20786 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 16 Bramblebush Drive
CITY Forestdale STATE MA ZIP 026442644 I TEL
FAX CELL 5086482934 EMAIL
•
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes Na
THIS APPLICATION SERVE AS THE ❑ El
FEES$ PERMIT N
PLAN REVIEW NOTES
! _
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-!, ':_ C-?, BLDP-23-003621
— CITY YARMOUTH MA DATE January 04, 2023 PERMIT#
JOBSITE ADDRESS 50 TASMANIA DR OWNER'S NAME GILLIS MARCIA A TR
G
OWNER ADDRESS MARCIA A GILLIS LVG TRUST 50 TASMANIA DR YARMOUTH PORT MA 02675 TEL
TYPE ()R OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT: ❑ 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. PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 BOND 0
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 Mark Moran LICENSE # 20786 SIGNATURE
MP ❑ MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP 0 # LLC ❑ #
COMPANY NAME: 1 ADDRESS. 16 Bramblebush Drive,
CITY Forestdale STATE MA ZIP 026442644 TEL
•
FAX CELL 5086482934 EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE:$ PERMIT#
PLAN REVIEW NOTES