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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRES ., W/ • I 11, . - OWNER'S NAME r
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TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUC TIONAL 0 RESIDENTIAL
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CLEARLY NEW:0 RENOVATION:: REPLACEMENT: PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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DEDICATED SPECIAL WASTE SYSTEMg
DEDICATED GAS/OILISAND SYSTEM J I� I —En i i- -
DEDICATED GREASE SYSTEM I I I I I,
DEDICATED GRAY WATER SYSTEM I�i I I I i fl
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0 COVERAGE:
a,t�ib� TiQ1kSh�e policy or its substantial equivalent which� ��S��S�
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INSURANCE
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sr._ ___ meets the requirements of MGL Ch.142. YES Q NO Q
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY:v OTHER TYPE OF INDEMNITY Q 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 [l 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 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 compl'-nos 'th -I ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /`
PLUMBER'S NAME t Joseph Ventresca LICENSE# IIMIIN SIGNATURE
MPD' JP: CORPORATION:3#3255 PARTNERS P®#I__ I LLC 0#
COMPANY NAME South Shore Heating and Cooling ADDRESS 57 Whites Path
CITY South Yarmouth STATE n ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL 508-360-5277 EMAIL joe@southshoreheatingcooling.com _
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