HomeMy WebLinkAboutBLDP-15-003237 A50 C
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+ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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talc z.0 CITY W,j!rydl I MA DATE PERMIT#IJ1-Op-1Y'00 7i']
JOBSI ADDRESS 1 I VI I Vlif0,1 (cam I OWNER'S NAMEakAitaaii0A, 1
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES[3 NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB if { F-
CROSS CONNECTION DEVICE r rmI
DEDICATED SPECIAL WASTE SYSTEM m i
DEDICATED GAS/OWSAND SYSTEM I__
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 1 I i
DEDICATED WATER RECYCLE SYSTEM j ( 6 ---( -i
DISHWASHER _
DRINKING FOUNTAIN ii
FOOD DISPOSER l
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR) I :1:- I; f I_ I
KITCHEN SINK -
LAVATORY —I - 1 1 1 - 1-
ROOF DRAIN 1 I i i
SHOWER STALL -i---- -- ii TT
SERVICE/MOP SINK I -'
TOILET i E 1 I �—i(—
URINAL r
WA R EASE`;_'LL -on. ' MN
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WA 12 PIPING ' i f ! i1I 'i
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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
UABIUTY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 BOND 0
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 ❑
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 cgrnace r'Moen provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C/
PLUMBER'S NAME Keith J.Farnham 1LICENSE# 11601 SIGNATURE
MPID JP CORPORATION[l#130RR C. PARTNERSHIP 0# ILLC®#
COMPANY NAME South Shore Healing&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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