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HomeMy WebLinkAboutBLDP&G-21-005515 T } MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y, 6, CITY YARMOUTH MA DATE 3/25/21 PERMIT# BLDP-21-005515 t JOBSITE ADDRESS 44 BRIAR CIR OWNER'S NAME RADOVINSKY ALEXEY L P OWNER ADDRESS DOUDOVA IRINA 20 CHESTNUT ST APT 502 CAMBRIDGE,MA 02139-4846 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES NO❑ FIXTURES : FLOORS--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/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❑ 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 Keith Famham LICENSE#1601 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME SOUTH SHORE HEATING& ADDRESS 57 White's Path C001 ING CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL info@southshoreheatingcooling.com 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK / CITY YARMOUTH MA DATE March 25,2021 PERMIT# BLDP-21-005515 f�- JOBSITE ADDRESS 44 BRIAR CIR OWNER'S NAME RADOVINSKY ALEXEY L G OWNER ADDRESS DOUDOVA IRINA 20 CHESTNUT ST APT 502 CAMBRIDGE MA 02139-4846 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES ❑ NO❑ 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 I 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❑ 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 Keith Famham LICENSE# 11601 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: SOUTH SHORE HEATING&COOLING ADDRESS. 57 White's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL infoRsouthshoreheatingcooling.com 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 v MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 5_—»t'� p'— v CITY MA DATE 3-2--z z1 PERMIT JOBSITE AJ 'ESS )4 14 81"\ate el���UP� OWNER'S NAME P OWNER ADDRESS TE'- l�'"DZZb FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL 0 RESIDENTIAL Er- PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:l ,/� PLANS SUBMITTED: YES El NO 0 --- FIXTURES Z FLOOR—, 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/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/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' 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 y signature on this permit application waives this requirement. t CHECK ONE ONLY: OWNER ❑ AGENT.E---"+ SIGNATURE OF OW R 0 GENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ccur e to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian 'th PriTai on of the Massachusetts State Plumbi g Code and- Chapter 142 of the General Laws. f ��y� ` PLUME NAMEC�h Iroz LICENSE# 1 1(�>{ IGNATURE MPPJP 0 ORPORATION l t t' P RTNERS IP 0# LLC 0# G CO � ,,�r � ADD'ESS ,i J� i-tJ�l. � �', Imo,���1 CITY 31 a� OL/ STATE' r�• ZIP (Z0K' TEL —/OS '1 FAX CELL EMAIL l bfje�t frlvl -vG./lt� � i i '_(4-6t-i M i