HomeMy WebLinkAboutBLDP-19-007292 ,A.V.S
L -'k,,\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I I-;, CITY Ya.v't bct '1.p?+ MA DATE fj Y� '; PERMIT#*/DP? ,OV.ret%
JOBSITE ADDRESS 6-J e,..._2. rcvfd 7L OWNER'S NAME BIZ r/G
OWNER ADDRESS ,6 cc t►- 4,1 ' TEL . .,... FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL El RESIDENTIAL ID
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:ED PLANS SUBMITTED: YES LI NOLI
FIXTURES 1 FLOOR— BSM 1 2 3 i 4 5 II 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM } ' _ ,
DEDICATED GAS/OIUSAND SYSTEM -
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER . Ran '
DRINKING FOUNTAIN UR_URRUIJIRRURj _
FOOD DISPOSER
IIIIIIIIIIIIIIII
FLOOR/AREA DRAIN MIK XIII'
INTERCEPTOR INTERIOR 1111111111111111111111111111FIIIIIIIIIIIIIIFFIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
KITCHEN SINK 1111111111111111F111111111r11111F1111111111111111F1111F11111111111111F1111F1111r
'coo LAVATORY miminiiiimmmi ,==mummium
ROOF - ..0r
vD SHOWER STALL
iii swan ,1 Riinn min
E J TOILET
URINAL
WASHING MACHINE CONNECTION 1 _ .
WATER HEATER ALL TYPES
1 p WATER PIPING
OTHER 1 j
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES LI NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E OTHER TYPE OF INDEMNITY 0 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 LI AGENT U
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 and cy/ate t t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c liance t al rtine rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
PLUMBER'S NAME_Keith J.Farnham LICENSE# `11601 / SIGNATURE
MPL JP® CORPORATION# 3698C 3PARTNERSHIP®# v LLC®# I
COMPANY NAME South Shore Heating&Cooling 3 ADDRESS 57 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508 398 6901
FAX 508-760-2681 ; CELL EMAIL Inc() e } ,a-Y,...Y r - , (,CX)‘i_te �,f O 1
GP 14
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