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a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
e- 41-7. -y CITY L� / 1 Crr MA DATE 111!�f i1 I PERMIT# ' t 3
JOBSITE ADDRESS /4 'n ' r girl • OWNER'S NAME �� I,
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL ❑ RESIDENTIAL0
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-, BSM 1 3 4 5 a 6 7 8 9 10 11 12 13 14BATHTUB � ( 1 "I ICROSS CONNECTION DEVICErit72a
iit[iimitHism:�,
DEDICATED SPECIAL WASTE SYSTEM '
i
� SS 1
DEDICATED GAS/OILISAND SYSTEMii
DEDICATED GREASE SYSTEM I lil_
DEDICATED GRAY WATER SYSTEM O I i
DEDICATED WATER RECYCLE SYSTEM I x I
DISHWASHER } '
DRINKING FOUNTAIN
FOOD DISPOSER r ,r 11 i'1 Au rI
FLOOR IAREA DRAIN J n ' -
KITCHEN SINK INTERCEPTOR(INTERIOR) I B* II I v ��, 4 � ,
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LAVATORY 11.11 Y IIIMIi aWANI r.'INEASI
ROOF DRAIN SHOWER STALL ` x•.11 u' ilii S
TOILET
111
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES I
WATER PIPING 2-,
T. L ,
SI 0.10.111011.10111111111111111011101111111011111101111101111110.11111110101111101111.011111
Mi us il SI Mill 11111111 LI
IOW Mt Ma 111110.10.1111111 i
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES C NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY C OTHER TYPE OF INDEMNITY ❑ BOND Q
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: OW, R ❑ AGENT 0
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; =nd =c ate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be ini1t all Per. ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Phillip Durfee LICENSE# 13774 4 •
SIGNATURE
MPC JP CORPORATION❑# PARTNERSHIP./ LLCC# 3152 ..
COMPANY NAME Durfee Plumbing and Heating,LLC ADDRESS 2A Huntington Ave
CITY South Yarmouth STATE MA ZIP 02664 . tr.s,..2.1,ds. :5 1
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FAX 508-258-0592 CELL 508-801.8004 EMAIL phil@durfeeplumbing.com I J III
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