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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CIiYROWN South Yarmouth MA DATE 6/21/2018 PERMIT II A44P/g-W 7999
• - JOBSITE ADDRESS 72 Breezy Point Road OWNER'S NAME Schneider
P • OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:i] REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO El
FIXTURES? FLOOR-6 BSM 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
• CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASJOIL/SANO SYSTEM •
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) ,
KITCHEN SINK 1
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET •
URINAL
WASHING MACHINE CONNECTION
• WATER HEATER ALL TYPES
WATER PIPING -
OTHER
Water to Remeerator 1
INSURANCE COVERAGE
I have a current lIabIlity Insurance policy or Its substantial equivalent which meets the requirements of MOL.Ch,142 YES ['NO 0
I IF YOU CHECKED YES,PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [a• OTHER TYPE 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.
CHECK ONE ONLY: OWNER 0 AGENT•❑
SIGNATURE OF OWNER OR AGENT
I hereby certify(hat all of the details and Information I have submitted or entered regarding this application are has and accurate to the best of my knowledge
and that all plumbing work end Installations performed under the permit Issued for We application will be In compliance with as Pertinent provision of the
Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTERNAME Andrew Levesque LICENSE# PL15162 /rG ATM"
MP El MOF 0 JP❑ JGF 0 LPG!0 CORPORATION 0# PARTNERSHIP❑# LLC 21# 3944
COMPANY NAME Harwich Port Heating&Cooling LLC ADDRESS 461 Lower County Rd
CITY Harwich-Port STATE MA ZIP 02646 TEL 508-432-3959
FAX 508-432-6075 cal. 508-958-4874 EMAIL andyAhphclIc.com
21AVE j/d/ 7
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