HomeMy WebLinkAboutBLDP-20-001230 (-Ivo e1/l4e7 p 1 "'w"f
S \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CtlY/roWN SOUTH YARMOUTH MA DATE 8/27/19 PERMIT# /2-10-C°''3d
JOBSITEADDRESS 20 CAPTAIN RYDER ROAD OWNER'S NAME MILLS
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ICI
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO
FIXTURES'. FLOOR-6 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _
• CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM _
DEDICATED GAS/OILISAND SYSTEM •
_DEDICATED GREASE SYSTEM l
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER '
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN - -
_INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET •
URINAL
WASHING MACHINE CONNECTION
• WATER HEATER ALL TYPES 1
WATER PIPING -
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch,142 YES [WNO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I ' OTHER TYPE 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
!wilt);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 applcation v4ll be In compliance with ell Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Andrew Levesque LICENSE# PL15162 GINIATUSE
MP It MGF❑ JP❑ JGF❑ LPGI El CORPORATION❑# PARTNERSHIP❑# LLC E(# 3944
• COMPANY NAME Harwich Port Heating&Cooling LLC ADDRESS 461 Lower County Rd
CITY Harwich-Port STATE MA zip 02646 TEL 508-432-3959
FAX 508-432-6075 CELL 508-958-4874 _ EMAIL andy@zhphclIc.com
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