HomeMy WebLinkAboutBLDP-15-000804 1 5D -----
.Si ., ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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;.�13=,W CITY W Yarmouth MA DATE 8/5/14 PERMIT# fW)P—/ET-cuK7'
JOBSITE ADDRESS 184 South Sea Ave.,Cottage#22 OWNER'S NAME Gary Manser
P OWNER ADDRESS TEL 413-374-9475 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL DI
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ,lla I _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM II i 1
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DEDICATED GAS/OIL/SAND SYSTEM __ -I
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM v% _ I
DEDICATED WATER RECYCLE SYSTEM f
DISHWASHER r,
DRINKING FOUNTAIN , (;
FOOD DISPOSER I
FLOOR/AREA DRAINIll --
INTERCEPTOR(INTERIOR) i „ (i_ __ i I
KITCHEN SINK I.
LAVATORY 1 , , _ J
ROOF DRAIN
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SHOWER STALL - ,I
SERVICE/MOP SINK __Ji ,I , , ,
TOILET
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WASHING MACHINE CONNECTIONfyP
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uu'„/„.fn 3Lf,j INSURANCE COVERAGE:
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policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND❑
OWNER'S INSURANCE WAIVER:lam 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
hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc rate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in cgp2plia wiMe Terthrefit pr 'sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Keith J.Famham LICENSE# 11601 SIGNATURE
MPD JP❑ CORPORATION D# 3698C PARTNERSHIP❑# LLC Elk
COMPANY NAME South Shore Heating&Cooling,Inc. ADDRESS 57 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES