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HomeMy WebLinkAboutBLDP-23-003504 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .r '_w; ty CITY YARMOUTH MA DATE 12/27/22 PERMIT# BLDP-23-003504 JOBSITE ADDRESS 110 CAPT CHASE RD OWNER'S NAME VENIOS CONSTANCE M P OWNER ADDRESS VACCARINO ALEXIS 83 CUMBERLAND RD LEOMINSTER,MA 01453-2025 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURFS 1 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 3 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION 1 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❑ 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 Ronald Hague LICENSE 1636 SIGNATURE MP 0 JP ❑ 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 El FEES$ PERMIT# PLAN REVIEW NOTES i • ^w MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK IE C§F l a.r rvto"`411 MA DATE 'Q PERMIT# 2 - 3 s o L( I ¢, JOBSITE DFESS VW 6-� Lk S4 C2- OWNER'S NAME Co,nS!-o v .- \J' ' QS � EC �72022 1 OWNER RCS t Z TEL(SC$) a ► --n F 1 FAX T�''{blEEb ' L E-666151446 TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALC6 RA CLEARLY NEW:0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO8 FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8' 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER ( • DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 3 • _ ROOF DRAIN SHOWER STALL I SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING { OTHER INSURANCE COVERAGE: { I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Et. NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i2r OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. • CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT L:l I hereby certify that all of the details and information I have submitted or entered regarding this application are e and accurate t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in fiance wi all 'ne rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME o(\ (A-0-1 v`-'r LICENSE# 7 L 3 L . IGNATURE MP In JP❑ , CORPORATION❑# PARTNERSHIP❑.# LLC 0# COMPANY NAME 1A,4 \ ) ADDRESS b a 0 o S o CITY 1)45\AZ) qq STATE �A ZIP t,3 TEL FAX CELLO)%3 41 -1(t P o EMAIL f 0 ) ke(7 G0 wt(4$ L. 1-7., I 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