HomeMy WebLinkAboutBLDP-20-002612 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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PERMIT# ,�zeP ®-�,f0/
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P OWNER ADDRESS V IM 0 J tlt 'P Q ' TEL TEL T 3 00 f FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Q
PRINT
CLEARLY NEW: Ej RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES® NO M
FIXTURES 7 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
G_r CROSS CONNECTION DEVICE i I ,
DEDICATED SPECIAL WASTE SYSTEM _ . j
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM 1
DEDICATED GRAY WATER SYSTEM j 1
DEDICATED WATER RECYCLE SYSTEM j ";,� i „. . _ , y._
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DISHWASHER T __
DRINKING FOUNTAIN 1
FOOD DISPOSER I -
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FLOOR/AREA DRAIN II
INTERCEPTOR(INTERIOR) I_
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SHOWER STALL 1
URINAL ,
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES , , I II.
WATER PIPING n• 1 1
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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 NO U
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY BOND 0-
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 tr nd u tot est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co " nc it al rtine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Keith J.Farnham LICENSE# 11601 SIGNATURE
MPLi JP Li CORPORATIONS# 3698C PARTNERSHIP®# LLCLJ#
COMPANY NAME South Shore Heating&Cooling, Inc. ADDRESS 57 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 1 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 ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES fr'� C 1
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