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HomeMy WebLinkAboutBLDP-21-002556 #142 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 11/5/20 PERMIT# BLDP-21-002556 "1 JOBSITE ADDRESS 579 BUCK ISLAND RD OWNER'S NAME MAPLEWOOD AT MAYFLOWER P OWNER ADDRESS 579 BUCK ISLAND RD WEST YARMOUTH 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 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 1 SERVICE/MOP SINK TOILET 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 0 OTHER TYPE OF INDEMNITY❑ 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 Ralph Giangregorio LICENSE 91339 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RALPH J GIANGREGORIO ADDRESS 188 Route 28 CITY Dennis Port STATE MA ZIP 02639 TEL FAX I I CELL I I EMAIL office@3gsplumbing.net 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 / A-P r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK � CITY W. MA DATE "PDX PERMIT# L 2-SSE, JOBSITE ADDRESS 5-2 ct )(‘j� l��cl )24 OWNER'S NAME 1rCtrio c � p OWNER ADDRESS £ TELSct 626V FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ FIXTURES 3 FLOOR-0 88M 1 2 3 4 s 8 7 8 9 10 11 12 13 f4 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GA.'OIUSAND 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 1 • SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ 1 INSURANCE COVERAGE: I have a current Jiability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. 7 E „ff IF YOU CHECKED YES PLEASE INDICATE TH5,TIPE OF COVERAGE BY CHECKING THE APPRO PRIATE BOX BELOW � �•.._. UABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND❑ I� j 4 ?IJ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter i1.42 of the, Massachusetts General taws,and that signature on thisrequirement.my 9 perinh application waives this CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and inforrratton 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 sunlit:Warmth be In nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. y� . PLUM8ER'S NAME f le k gcl to ,,,* `i r•• LICENSE# of 13c7 A E MPEI JP❑ CORPORATION # o( PARTNERSHIP 0# LLC❑# COMPANY NAME 6 S Piu:".�m}rl'` + eci-1 i , ADDRESS l'ic'c Ma CITY raoilyitc, STATE Irr ' ZIP ( 't` lo3° TEL 1. of - • FAX, :'6- L In 4,�"I CELL ""' EMAIL .b