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HomeMy WebLinkAboutBLDP-21-005113 1 — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 3/10/21 PERMIT# BLDP-21-005113 r e .t • JOBSITE ADDRESS 108 BERRY AVE OWNER'S NAME mary miller P OWNER ADDRESS 108 BERRY AVE WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 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/OIUSAND 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 El OTHER TYPE OF INDEMNITY El BOND El 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 Troy Gilbert LICENSE 1A573 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP El# LLC ❑# COMPANY NAME COASTAL MECHANICAL ADDRESS 21 L Fruean Ave CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL lisa@coastalphc.com app- 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 s ram` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1r a ri =a_I ' CITY West Yarmouth 1 MA DATE 03/09/2021 _ ' PERMIT# 61012- 2-(- CGS 113 JOBSITE ADDRESS 108 Berry Ave OWNER'S NAME Miller Residence 1 POWNER ADDRESS 23 Otis Lane-Bay Shore,NY 11706 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL ® RESIDENTIAL 0 PRINT CLEARLY NEW:® RENOVATION:LI REPLACEMENT:LI PLANS SUBMITTED: YES 0 NO® FIXTURES 1. FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I ' CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM t EOM MI DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM d DEDICATED WATER RECYCLE SYSTEM 1 DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) I= KITCHEN SINK 1 LAVATORY " ROOF DRAIN • SHOWER STALL SERVICE/MOP SINK TOILET ;, URINAL WASHING MACHINE CONNECTION q �_ WATER HEATER ALL TYPES 1 _,_ IR I WATER PIPING OTHER 11.11111111111111111111111M11111.111,.. .1 , , ow , , Mg ' 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 Q OTHER TYPE OF INDEMNITY ® BOND Ej 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 LI AGENT LI 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. /T6Q/!t PLUMBER'S NAME Troy Gilbert I LICENSE# 13573 pie SIGNATURE MPL JP LI CORPORATION 0# I PARTNERSHIP®# LC # 4350 COMPANY NAME Coastal Mechanical I ADDRESS 21 L Fruean Ave CITY South Yarmouth STATE MA ZIP 02664 TEL 508-737-8747 FAX CELL 508-850-6599 EMAIL lisa©coastalphc.com