HomeMy WebLinkAboutBldp-19-005152 , $ \ '0- .1Cs
• fir MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'F--4i
as CITY S.Yarmouth j MA DATE 2/27/19 PERMIT#/i/12/��S'a3
t
JOBSITE ADDRESS 204 South St. OWNER'S NAME Elaine Reilly
POWNER ADDRESS 736 Andover St.,Lowell,MA 01852 TEL 207-831-3784 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL O
PRINT
CLEARLY NEW:El RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NOD
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
;;;)c7 CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM l
DEDICATED GAS/OIL/SAND SYSTEM II 1 I
DEDICATED GREASE SYSTEM 1 _ I
DEDICATED GRAY WATER SYSTEM I I
DEDICATED WATER RECYCLE SYSTEM mum miti En ow NE, 7
DISHWASHER - _ -
DRINKING FOUNTAIN i r -- t
FOOD DISPOSER I
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR) ;
KITCHEN SINK
LAVATORY I j
ROOF DRAIN I
SHOWER STALL .. I
SERVICE/MOP SINK
TOILET
URINAL I ;'
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING . I [ 1 1
OTHER I 1 f l 1 •r 1
F , 11
1 ,
, 1 1 1 , i
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY n OTHER TYPE OF INDEMNITY i^..s' BOND L
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 ❑
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 a a.�ur o the b of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp• ce/ al,P=rtinent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Keith J.Famham LICENSE# 11601 SIGNATURE
MP❑ JP❑ CORPORATION 0# 3698C PARTNERSHIP❑# LLC❑#
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 .1►`r�G e NIV 6h0r2hecmr,SCOO)i r‘(it .Corti,
��
1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
F.' ' 19 0° 75
is CITY S.Yarmouth MA DATE 2/27/19 ,PERMIT#��.>7G"_
JOBSITE ADDRESS 204 South St. 'OWNER'S NAME Elaine Reilly
GOWNER ADDRESS 736 Andover St.,Lowell,MA 01852 TEL 207-831-3784 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
cp BOILER 1
BOOSTER
CONVERSION BURNER U I I1
COOK STOVE
DIRECT VENT HEATER
DRYER 1 it II
FIREPLACE
FRYOLATOR I, II.
FURNACE iIiiIIIiIiIllhiIi
UNVENTED ROOM HEATER
WATER HEATER
OTHER 11 ,
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE 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 ❑
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 acc to o t y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp' ce wit all pr 'sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Famham LICENSE# 11601 SIGNATURE
MP U MGF 0 JP❑ JGF 0 LPG!0 CORPORATION Q# 3698C PARTNERSHIP❑# LLC❑#
COMPANY NAME: South Shore Heating&Cooling, ADDRESS 57 White's Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL
N
1 � �
��