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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
M/ CITY Yarmouth port MA DATE 08/13/18 PERMIT 4"ACIP—N-017/IN
JOBSITE ADDRESS 14 Strawberry Lane OWNER'S NAME Joan Perera
POWNER ADDRESS r3 Birchwood Ln.,Lincoln,MA 01773 TEL 508-362-3971 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 'EDUCATIONAL ❑ RESIDENTIAL D
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:Q PLANS SUBMITTED: YES❑ NO0
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB �� ��
CROSS CONNECTION DEVICE 1 r ,;�M`�� � —1 t
DEDICATED SPECIALAWASTE SYSTEM ni
DEDICATED GAS/OIL/SAND SYSTEM i i J '
DEDICATED GREASE SYSTEM , , I „ 1 1
DEDICATED GRAY WATER SYSTEM IIIMMILIMILINEM111111flatI1-1——I
DEDICATED WATER RECYCLE SYSTEM _ I = ISI
DISHWASHER ��_
DRINKING FOUNTAIN1.
FOOD DISPOSER
_ 1
FLOOR/AREA DRAIN - - IR III
1, 1
INTERCEPTOR(INTERIOR) _ 1.1.11111111111111.
KITCHEN SINK � 7
LAVATORY a
ROOF DRAIN i S .' !'
SHOWER STALLI a
SERVICE/MOP SINK7
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TOILET
URINAL , �Ma'I i 1 --1
WASHING MACHINE CONNECTION �!
WATER HEATER ALL TYPES I an, sI1. 1_
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WATER PIPING
OTHER 1=11111=111 .1110Mi
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YES a 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.
CHECK ONE ONLY: OWNER ❑ AGENT 0
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 a d urabest of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comps II Pertine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Keith J.Famham LICENSE# 11601 SIGNATURE
MPO JP CORPORATION 0# 3698C PARTNERSHIP 0# LLCD#
COMPANY NAME South Shore Heating&Cooling,Inc. ADDRESS 57 Whites Path
CITY South Yarmouth STATE MS ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL illa EMAIL
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