Loading...
HomeMy WebLinkAboutBLDP-22-002986 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • v CITY YARMOUTH MA DATE 11/23/21 PERMIT# BLDP-22-002986 E � - JOBSITE ADDRESS 54 CAPT RYDER RD OWNER'S NAME[Simone Ambersly P OWNER ADDRESS 54 CAPTAIN RYDER RD SOUTH YARMOUTH,MA 02664-1631 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES ID NO❑ FIXTURES 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 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 TYPE 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'S NAME David Renzello SR LICENSE 173886 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 16 1/2 Foley St CITY Attleboro STATE MA ZIP 027031806 TEL FAX CELL EMAIL PERMITS@REBATHNEWENGLAND.COM ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES 4. 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK rn_ CITY MA DATE' (( I PERMIT# 2-1.- - CI'' -- - - SC • JOBSITE ADDRESSSti /IA rtfOiROWNER'S NAME! P ram_ OWNER ADDRESS TELZ '9�/w F TYPE OR OCCUPANCY TYPE COMMERCIAL 1.,_1 EDUCATIONAL '_,_I RESIDENTIAL T PRINT __ CLEARLY NEW: [. ,! RENOVATION:F. REPLACEMENT:H PLANS SUBMITTED: YES y, NO! 1 FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - 1 I,._ -- - i- - - I. ___ CROSS CONNECTION DEVICE ! I DEDICATED SPECIAL WASTE SYSTEM � �� T 1 DEDICATED GAS/OIL/SAND SYSTEM ' _ DEDICATED GREASE SYSTEM 1 u . _" DEDICATED GRAY WATER SYSTEM 1 11 n 1 .. _ _U_ 1 DEDICATED WATER RECYCLE SYSTEM i "- � r — , _ ' I i I. ,. JI ;I DISHWASHER I _ _ ) ��_� � � � , DRINKING FOUNTAIN I N -_ir_ _w _: __ _I I _ y, �. -. L. ._. __I �I II I FOOD DISPOSER r_ _ , FLOOR/AREA DRAIN I.. ]I I . . _I . Ii INTERCEPTOR(INTERIOR) L 1 _ i- I^ h_` I 1 � . 1 KITCHEN SINK LAVATORY 1 ( � , �- - -' 3 I 1 ROOF DRAIN - i ---' SHOWER STALL i '1 U SERVICE/MOP SINK I i_ 1' I' I sip I TOILET i 1 I 1? I { I- URINAL 1 I'; j i i1 —1_ �__ i ' I 1 _WASHING MACHINE CONNECTION II + WATER HEATER ALL TYPES j � i-1 - ,, m WATER PIPING L I 1 F---� I 1-- s ' valve _ c_ .� _ OTHER _ � I 1 �'_ __ =1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1µ-I NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 vt OTHER TYPE OF INDEMNITY L_JI 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. CHECK ONE ONLY: OWNER 1 , I AGENT I 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 an ac rate t e st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance a pr vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. tikr PLUMBER'S NAME,David M Renzello Sr � � „ LICENSE# 110886 ; SI NA URE MP;e�' JP I `:, CORPORATION 1 # (PARTNERSHIP• #, I LLC I# COMPANY NAME IHIP Construction LLC J ADDRESS J 2C Morgan Mill Rd g CITY Johnston STATE RI i ZIP 02919 1 TEL 401-942 7897 FAX 1 1 CELL EMAIL ,permits a rebathnewengIand.com