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HomeMy WebLinkAboutBLDP-23-003955 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 10 CITY YARMOUTH MA DATE 1/19/23 PERMIT# BLDP 23 003955 kp E JOBSITE ADDRESS 15 BURCH RD OWNER'S NAME FERULLO GLORIA R TR P OWNER ADDRESS 26161 SUMMER GREENS DR BONITA SPRINGS,FL 34135 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES El NO❑ FIXTURES z 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 WATER PIPING 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 0 OTHER TYPE 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'S NAME Ronald Hague LICENSE 1636 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RONALD J HAGUE ADDRESS 62 NEW BOSTON RD CITY DENNIS STATE MA ZIP 026381901 TEL FAX CELL EMAIL ronhague@comcast.net ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE 0 ❑ FEES$ PERMIT# PLAN REVIEW NOTES • $J, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 956' ! I YE Y� yA t�0�1k MA DATE L `k ,a3 PERMIT* JOBSITE ADDRESS I E a(A OWNER'S NAMER C.\na l-.1 p e r k I O N 19WNtlt ADC RESS TELf r6 9 ad 1 -1$ I FAx BF t" CY TYPE COMMERCIAL❑PRINT EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:❑ RENOVATION:® REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 8 FIXTURES 7 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN _ SHOWER STALL SERVICE/MOP SINK TOILET URINAL i WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING II { OTHER INSURANCE COVERAGE: { I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D 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 ❑ 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 apQfcation waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT kki I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd 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 co p nce with all n¢nt sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `w/1 !/ — PLUMBER'S NAME LICENSE#1(0'6 C SIGNATURE MP JP❑ a \CORPORATION 0# PARTNERSHIP❑.# LLC 0# COMPANY NAME ` t-C l k e \ ADDRESS D t\i-€ O S h Q0 a CITY bit.hv;S STATE "^lYl- ZIP 0ab3. TEL FAX CELL l Sb L y -c y Pe EMAIL Co Ca rnCc c 4-, 6, r ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTIO NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 � FEE: $ PERMIT# PLAN REVIEW NOTES