HomeMy WebLinkAboutBLDG-19-003079 2MASSACHUSET�TSS, ����C ! _'UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
•p'�e CITY yip-ma a V Il(-i I MA DATE I PERMIT# /�i "�on)--
JOBSITE/ADDRESS / e (A.41 i-64-0-0_,*(4.0WNER'S NAME A; 1/ catetp4.2 I
P OWNER ADDRESS }/rim 0frill" I TEL 744-7/C3 JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:Q PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUBME f, - IrtlIMMIIIIII
CROSS CONNECTION DEVICE r r
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM IL Li
..:— 1 : d , .,,,,1 i,,,,, , i
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN I
FOOD DISPOSER I I _, ',
FLOOR/AREA DRAIN 1 I f
INTERCEPTOR(INTERIOR) I
KITCHEN SINK i i i I
LAVATORY I
ROOF DRAIN II I I
SHOWER STALL
SERVICE/MOP SINK
TOILET _ -
URINAL r
WASHING MACHINE CONNECTION I II
Stj WATER HEATER ALL TYPES
WATER PIPING
OTHER
, ,mow . 1
; . I _ i 1
II I
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D 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 ❑
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 , • r- - . --: of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In compli.;.•- , all 'ertinent, ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. At1y
PLUMBER'SNAME Keith J.Farnham LICENSE# 11601 I' SIGNAT •
MPO JP CORPORATION Q# 3698C PARTNERSHIP❑# LLC 0#
•
COMPANY NAME South Shore Heating&Cooling, ADDRESS 57 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT# I "'" " yc/.17-6 (�'�/�/j//� /�t
PLAN REVIEW NOTES 412/'/ /( `CE0
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