HomeMy WebLinkAboutBLDP-16-000323 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
s.® � CITY I MA DATE 4_15 I P RMIT#/PAPP/a'�o 9.1y
L JOBSITE AD ESS 1
5 j I2GI OWNER'S NAME' d Y '
POWNER ADDRESS ws .._ TEL� �'�F'I► IFAXL_.a. -1
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:0 RENOVATION: REPLACEMENT:(�' PLANS SUBMITTED: YES D N0
FIXTURES 1. FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB �, _._ (_ E.__ �' —_I - .� �'n�
CROSS CONNECTION DEVICE i 1 _ r
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DEDICATED SPECIAL WASTE SYSTEM l
Rum
DEDICATED GAS/OIL/SAND SYSTEM i
DEDICATED GREASE SYSTEM I , , I [ I __ !In j irl
DEDICATED GRAY WATER SYSTEM I1 r,. 6 1 zF J
DEDICATED WATER RECYCLE SYSTEM ,.. .. _ a ...
DISHWASHER i_ ..� __-
DRINKING FOUNTAIN I _ 'I__._ , �'l
FOOD DISPOSER MK _ ..„, ...
FLOOR/AREA DRAIN I�W .. .I . _._ i
BMIIM MN
INTERCEPTOR(INTERIOR) __ a
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KITCHEN SINK Inn Mill J NMI Mal NUM WM . NM
LAVATORY InsiMIIIIIIMII � l'I
ROOF DRAIN .,,....�
SHOWER STALL I,Y� L ..
SERVICE/MOP SINK
TOILET . .. rin fAll 1l
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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 J NO G
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L: OTHER TYPE OF INDEMNITY L 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 El AGENT LI
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 cplia ce 'h a ertinentprovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Keith J.Farnham J LICENSE#[1601 j SIGNATURE
MP 0 JP,,,J CORPORATION L #{ i/3 C (PARTNERSHIP #[ LLC L#[ �1
COMPANY NAME South Shore Heating&Cooling,Inc. ADDRESS 157 Whites Path
CITY SouthYarmouth j STATE I MA I ZIP 02664 t4d TEL 508-398-6901
FAX [508 760 2681 CELL I� EMAIL [}