HomeMy WebLinkAboutBLDP-15-005797 /r1‘.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
"= CITY South Yarmouth 1 MA DATE 01/21/15 'PERMIT# I L/,P-5--OO 7?7
JOBSITE ADDRESS 18 Mistletoe Lane OWNER'S NAME Barbara Clancy 1
P OWNER ADDRESS __ I TEL 508-760-4967 IFAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL
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CLEARLY NEW:0 RENOVATION:® REPLACEMENT:El PLANS SUBMITTED: YES El NO®
FIXTURES-1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB . _ ___ _ ''
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM .- �_
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM ;�
DEDICATED WATER RECYCLE SYSTEM I J ' , B
DISHWASHER
DRINKING FOUNTAIN fi '
FLOOR nun ,
KITCHEN SINK jig ' T Mt
LAVATORY f T `I ._
ROOF DRAIN I
SHOWER STALL e II _ m '` .:I ' l I
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES 1
WATER PIPING 1 , - f 1
OTHER h li
L
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 Ei OTHER TYPE OF INDEMNITY Li BOND Li
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 El
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 com i nce th P ' rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,tkewl
PLUMBER'S NAME Keith J.Farnham LICENSE# 11601 SI NATURE�'
MP: JPD CORPORATION S# 3698C PARTNERSHIP®# i LLC #
COMPANY NAME South Shore Heating&Cooling,Inc. ' ADDRESS 57 Whites Path
CITY South Yarmouth STATE MA 1 ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL
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