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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY west yarmouth MA DATE 9/26/2019 PERMIT# ✓"* V Are
JOBSITE ADDRESS 74 trowbridge path OWNER'S NAME gloria gage
P OWNER ADDRESS TEL 3392061261 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El
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CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14
BATHTUB
S� CROSS CONNECTION DEVICE ! 4
DEDICATED SPECIAL WASTE SYSTEM i..._._._.r.....o.m...L.m..mik...mmrimo.r.im7
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM ______ r Ar.-
DEDICATED GRAY WATER SYSTEM 1
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ` ;
DRINKING FOUNTAIN ( l
FOOD DISPOSER If Q Q ( 1 I
FLOOR/AREA DRAIN D , I J
INTERCEPTOR(INTERIOR) L _ _ _ ! I
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KITCHEN SINK J f Q Q
LAVATORY L
ROOF DRAIN
SHOWER STALL U Jinli,
SERVICE/MOP SINK
TOILET
URINAL r I r ( I I
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES x j
WATER PIPING ('
OTHER J i�
I ,
I 1 i 1 I II II
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO 0
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 ❑
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 alid ccu T the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com h wit allerti nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i'
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PLUMBER'S NAME Keith J.Famham LICENSE# 11601 SIGNATURE
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MP❑ JP❑ CORPORATION# 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 info@southshoreheatingcooling.com
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