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HomeMy WebLinkAboutBLDP&G-23-003799 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 1/12/23 PERMIT# BLDP-23-003799 I' JOBSITE ADDRESS 22 CLARA ST OWNER'S NAME ROMAN CATH BISHP OF FALL p OWNER ADDRESS CIO ST PIUS X PARISH STATION AVE SOUTH YARMOUTH,MA 02664 RIVER P TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES❑ NO m FIXTURES 1 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 m 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 MICHAEL HANSEN LICENSE 15906 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RUSTYS INC ADDRESS 222 MID TECH DR CITY W YARMOUTH STATE MA ZIP 026731111 TEL 5087751303 FAX CELL EMAIL T •' -4 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK ,17 CITY YARMOUTH MA DATE January 12,2023 PERMIT# BLDP-23-003799 JOBSITE ADDRESS 22 CLARA ST OWNER'S NAME ROMAN CATH BISHP OF FALL RIVER G OWNER ADDRESS CIO ST PIUS X PARISH STATION AVE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 111 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 © NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER 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 Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME MICHAEL HANSEN LICENSE# 15906 SIGNATURE MP❑ MGF © JP❑ JGF El LPG' ❑ CORPORATION❑# PARTNERSHIP El# LLC ❑# COMPANY NAME: RUSTYS INC ADDRESS. 222 MID TECH DR, CITY W YARMOUTH STATE MA ZIP 026731111 TEL 5087751303 FAX CELL EMAIL i 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