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HomeMy WebLinkAboutBLDP-22-006441 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK LrI CITY YARMOUTH MA DATE 5/9/22 PERMIT# BLDP-22 006441 JOBSITE ADDRESS 7 CIRCUIT RD WEST OWNER'S NAME NUGENT MARK C P OWNER ADDRESS 468 PLAIN ST SUITE 3 MARSHFIELD,MA 02050-2252 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 9 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURFS • FLOORS—, 8SM 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❑ OTHER TYPE OF INDEMNITY❑ BOND 0 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 jeff ryan LICENSE 301068 SIGNATURE MP 0 JP © CORPORATION ❑# PARTNERSHIP 0# LLC 0# COMPANY NAME ADDRESS 8 russells path CITY marstons mills STATE MA • ZIP 02648 TEL FAX CELL 5082803678 EMAIL rosandsky@gmail.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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK R .= v /aVT� 9` ,per 2-z— cj'1 ( = =I_I,,,;�,�.._._ MA DATE mil/-` - PERMIT# moo / MAY 09 ZO �I0B IT E ADDRESS C /�Z�a.0 �T/ OWNER'S NAME% D /�/e 0 ER ADDRESS %_gq/in(7 TEL 77c4-09J91S6t4FAX B ILDIN$-DEPARTMENT BY r-- f-f UP*NCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,) PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:, PLANS SUBMITTED: YES❑ NO MO FIXTURES 1. 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM r 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 j URINAL T 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 LIABIUTY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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. ts CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I I hereby certify that all of the details and information I have submitted or entered regarding this application are tru a ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co i all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME Z �Y LICENSE 01065 SIGNATURE MP❑ JPA �j,QCO�RPPORATION❑# PARTNERSH rP/❑.# 7� LLC, # COMPANY NAME �C -- / i2 ✓/ ' ADDRESS,q I Cora� �/✓�%'-/ CITY/4/0 -C�LAKC 41/7- €-c STATE ZIP ©26 8 TEL FAX CEL EMAILOS/7Nas1r r @ Alf// /C..E/n7 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