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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_• �. 4 CITY South Yarmouth MA DATE 2/19/2015 PERMIT# l -IY-1 006er9
JOBSITE ADDRESS 10 Nickerson Farm Rd OWNER'S NAME Dunakin
POWNER ADDRESS m TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL 0
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CLEARLY NEW: ® RENOVATION:® REPLACEMENT:Q PLANS SUBMITTED: YES® NOD
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1 I
DEDICATED SPECIAL WASTE SYSTEM {
DEDICATED GAS/OIL/SAND SYSTEM {
DEDICATED GREASE SYSTEM [ (_ !� I
DEDICATED GRAY WATER SYSTEM I ] 1
DEDICATED WATER RECYCLE SYSTEM I 1 r
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER „ 1
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) 11
KITCHEN SINK
LAVATORY ,
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET ..,. i m..r =I � 1 1 ,.
URINAL ,
WASHING MACHINE CONNECTION {
WATER HEATER ALL TYPES 1 1 I 1 1
WATER PIPING
OTHER
, I 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 Q 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 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 co lian wi en rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME Keith J.Famham LICENSE# 11601 SIGNATURE
MPD JP® CORPORATION # 3698C PARTNERSHIP®# ILLC 0# I
COMPANY NAME South Shore Heating&Cooling, Inc. ADDRESS 57 Whites Path
CITY South Yarmouth I STATE MA ZIP 02664 TEL 508-398-6901 I
FAX 508-760-2681 CELL EMAIL
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