HomeMy WebLinkAboutBLDP-16-000563 ii SJ, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
� gre lta ' CITY F aCiV1.61 Vairrnar I MA DATE 17/70/X1 PERMIT#/N-.0f'/l'WOO 9 4
JOBSITEADDRESS0/V.A/Mil r ( OWNER'S Ai*' K/
P OWNER ADDRESS *3' ±7 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL a
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑+
FIXTURES 1 FLOOR-. I 1 2 3 4 5 6 7 8 r 9 10 11 12 13 14
BATHTUB If , 1I r
CROSS CONNECTION DEVICE ‘,-__F - — -
DEDICATED SPECIAL WASTE SYSTEM _ - m
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DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM - -
DEDICATED WATER RECYCLE SYSTEM -N [ - '
DISHWASHER .
DRINKING FOUNTAIN Sr— 7 1 PI 8
FOOD DISPOSER P. it i j 1
FLOOR/AREA DRAIN
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INTERCEPTOR(INTERIOR) (—
KITCHEN SINK
LAVATORY , .r "`-
ROOF DRAIN ,
SHOWER STALL Ii
SERVICE/MOP SINK
TOILETst
URINAL m*I 1r r
WASHINGMAGNIN� E ONNECTION �, V -
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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 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY❑+ OTHER TYPE OF INDEMNITY 0 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: 0 . r R 0 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 = - e to the best of my knoMedge
and that all plumbing work and Installations performed under the permit issued for this application will be In corn• a./ ,, all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / .
PLUMBER'S NAME Phillip Durfee LICENSE# 13774 i SIGNATURE
MP JP El CORPORATION D# PARTNERSHI'MI# LLCEI# 3152
COMPANY NAME Durfee Plumbing&Heating LLC ADDRESS 2A Huntington Ave.
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-619-3078
FAX 508-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;joy@durfeeplumbing.com
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