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HomeMy WebLinkAboutBLDP-23-004737 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK k- ,_ I CITY YARMOUTH MA DATE 2/27/23 PERMIT# BLDP-23-004737 ,`' JOBSITE ADDRESS 65 CIRCUIT RD OWNER'S NAME DIPIAllA DAVID P OWNER ADDRESS DIPAllA DEBRA 11 BERGEN AVE HILLSDALE,NJ 07642 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY t NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURFS z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 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 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 El 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'S NAME Albert Perry LICENSE 146791 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ALBERT J PERRY ADDRESS 10 HERON CIR CITY MASHPEE STATE MA ZIP 026493418 TEL FAX CELL EMAIL ajpplumbingandheating@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ rit,rb GIBS, FEES$ PERMIT# PLAN REVIEW NOTES f ... E I V • �l� CHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORKX MA DATE �' �"�/ 3 PERMIT# — �701 !'7---v7 2 a r�� / c2 c u r OA 2 2 QuiLpi JOBSITE . IliRESS &r OWNER'S NAME v'd O.�13/ NGD RT Ey__ S E _owN AD DRESS I i Q C'A) A v HI LiSat-t(Ir TEL FAX n),J• p 7 G Y TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:© REPLACEMENT:2 PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1. FLOOR—► BSM 1 2 3 4 5 6 7 6' 9 10 11 12 13 14 BATHTUB I CROSS CONNECTION DEVICE _ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM • DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ • _ DEDICATED WATER RECYCLE SYSTEM 1 DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER r _ _ FLOOR/AREA DRAIN _ _ INTERCEPTOR(INTERIOR) _ KITCHEN SINK LAVATORY I • ROOF DRAIN _ _ SHOWER STALL • SERVICE I MOP SINK I TOILET I _ URINAL _ WASHING MACHINE CONNECTION _ • WATER HEATER ALL TYPES WATER PIPING , . -\ { OTHER _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES(21, NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. • Q CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT L'J 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 al Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. GG��. -----, PLUMBER'S NAME LICENSE# 2 C,"1`3./ GNATURE MP 0 JP f,C1._ CORPORATION 2# PARTNERSHIP❑.# LLC 0# COMPANY NAME 114- P4-?242 1•P( v/ c 6 I" H f ? NC ADDRESS (n y C=,,20 A) C/XIS G C CITY 71-1 Cir:Si'l e L�' — STATE I' ZIP D 2 G P TEL ..5-6 1.-G V' 9 f? 9 FAX CELL 1 OS^6V" ?1 , EMAIL '4•J PP i 0 A a i a j wn...0 A(4", e•Yo‘„ov.co•� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES