HomeMy WebLinkAboutBLDP-19-003902 J" IZI, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-...lik tC CITY south yarmouth I MA DATE 12/26/2018 PERMIT#jiL, ��
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JOBSITE ADDRESS 733 willow st OWNER'S NAME barbara commons
P OWNER ADDRESS TEL 5082801880 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL D
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑+ PLANS SUBMITTED: YES 0 NO❑
FIXTURES 7 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 11111=i=,llit� i�M _ _gi
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CROSS CONNECTION DEVICE �9 uhuIII1uh11_________
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DEDICATED SPECIAL WASTE SYSTEM 1111
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEMl MR
DEDICATED WATER RECYCLE SYSTEM iFiImIiIisuIuhi
DISHWASHER
DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) II „.,- .: s:I asiKITCHEN SINK
LAVATORY ! ,* !I
ROOF DRAINI !'. Imo,SHOWER STALL 1SERVICE I MOP SINK III
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TOILET i I' �_
URINAL j 1. r.
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1 1 I
WATER PIPING
0-11- 41 Int �111111,4011
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES O 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 ❑
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
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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 tru: .rate , best of my knowledge
. and that all plumbing work and installations performed under the permit Issued for this application will be in co all • es . ov'sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
A JAW
PLUMBER'S NAME Keith J.Farnham LICENSE# 11601 / SIGNATURE
MPO JP❑ CORPORATIONO# 3698C PARTNERSHIP❑# LLC❑# 1
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
. P2-60 GE
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