HomeMy WebLinkAboutBLDP-15-005802 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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:-Nis: CITY Yarmouth1.
MA DATE 12/17/14 PERMIT# UP/�
JOBSITE ADDRESS 79 Barnicle Rd. I OWNER'S NAME Ann Smith
P OWNER ADDRESS SAME I TEL 508-362-2357 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL El
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑
( ''''�) PLANS SUBMITTED: YES❑ No CI
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 67 8 9 10 11 12 13 14
BATHTUB , _ - r [ r ri r r I_
CROSS CONNECTION DEVICE 1 1- l
DEDICATED SPECIAL WASTE SYSTEM I�,�_i Siallaillaillit um
DEDICATED GAS/OILISANDSYSTEM _IRssnaaRIaIRaI*
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM a,stINK Si Sim. �, � �
D SHICATED WASHERATER RECYCLE SYSTEM MR la Mt n MIN NM� s
DRINKING FOUNTAIN iliNalill ��ena �i�,ralilla=MK
FOOD DISPOSER
FLOOR MREA DRAIN R#•M P ' *R aas
INTERCEPTOR(INTERIOR) I .� INKITCHEN SINK
LATORY MS ROOF DRAIN IN
IURIUURIR
TOILET SINK I IOa
SHOWER STALL
URINAL al-tit flfl la�1�� �
WATERH ATERWASHING INE ALLTYPESCTION ai' � � ��
WATER PIPING SiiRIIU'RjjU
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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 Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑+ 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 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 ccur to to the est of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in co lance ith I P ent rovision of the '—
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER'S NAME Keith J.Famham LICENSE# 11601 SIGN RE-
MP❑+ JP❑ CORPORATION0# 3698C PARTNERSHIP 0# LLC 0#
COMPANY NAME South Shore Heating&Cooling,Inc. ADDRESS 57 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 I TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL ' p
(A if
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT El ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES