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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY south armouth MA DATE 11-9-2016 PERMIT
JOBSITE ADDRESS 133 hatch rd OWNER'S NAMEJ curt baker
POWNER
ADDRESS TEL774-836-7975 FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY
NEW: ® RENOVATION: ® REPLACEMENT: E PLANS SUBMITTED: YES ® NO®
FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 11 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 E] OTHER TYPE OF INDEMNITY [j BOND E
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 [j AGENT
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 a cur the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp ce i II Pe in nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I Keith J. Farnham LICENSE # F1166i SIG RE
MPE] JP® CORPORATION# 3698C PARTNERSHIP®# LLC0#
COMPANY NAME South Shore Heating & Cooling, Inc. ADDRESS 157 Whites Path
CITY South Yarmouth STATE MA ZIP 102664 TEL 508-398-6901
FAX 508-760-2681 1 CELL EMAIL
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