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,- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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f::AWLS CITY[R-( /IptV� MA DATE (Q lX PERMIT# P1 7` ra
JOBSITEADDRESS Liq bink,oycl ilk_ 1 OWNER'S NAME 11 Sam0 I
P OWNER ADDRESS I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL CI EDUCATIONAL 0 RESIDENTIALII;'
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES T FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB j _ - [I , r 1 1 r
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CROSS CONNECTION DEVICE i
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DEDICATED SPECIAL WASTE SYSTEM -so_DEDICATED GAS/OIUSAND SYSTEM i
DEDICATED GREASE SYSTEM ras
DEDICATED GRAY WATER SYSTEM
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FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET �
URINAL
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WASHING MACHINE CONNECTION n a r r
WATER HEATER ALL TYPES
WATER PIPING
OTHER i l 1
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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
UABILITY INSURANCE POUCY Q OTHER TYPE OF 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 ❑ 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 accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In comp!'.nce 'th . -ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A A
PLUMBER'S NAME Joseph Ventresca LICENSE# 15742 /-at'4 Al ,—SIGNATURE -
MPD JP 0 CORPORATION E]# 3255 PARTNERS P❑# ILLC❑#WSb
COMPANY NAME South Shore Heatin and Cooling I ADDRESS 57 Whites Pathil Z-3
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CITY South Yarmouth I STATE MA ZIP 02664 TEL 508-398-6901 '. 'S ; II
FAX 508-760-2681 CELL 508-360-5277 EMAIL hoe@southshoreheatingcooling.com ili •t I
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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