BLDP-20-001429 - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ay; CITY south yarmouth MA DATE 8/30/2019 PERMIT# P-o 0 /7
JOBSITE ADDRESS 9 captain smalls rd OWNER'S NAME catherine hutchins
POWNER ADDRESS TEL 3942574 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ NOLI
FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I'
CROSS CONNECTION DEVICE ` , 3 11 a 1 1 i ( I
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM 1 1 U ll _ 11 1 , 1 1
DEDICATED GREASE SYSTEM r 1 11 JI U 1 I
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM l � � B U I 1 11 � I
DISHWASHER _ 1 1_ U _- 1 I 0HL____}
DRINKING FOUNTAIN I' 1
FOOD DISPOSER U _ I U- U is ° I 1 _ i
FLOOR/AREA DRAIN 1 I I U I I I 1
INTERCEPTOR(INTERIOR) 1 I IJ U I I I I
KITCHEN SINK 1 I U U I
LAVATORY ,-..
ROOF DRAIN U 1
SHOWER STALL I
RIEIMOPSINK
TOILET [ - -___ _. -
URINAL
WASHING MACHINE CONNECTION 1 T
WATER HEATER ALL TYPES x
WATER PIPING l 1
OTHER
I �' _ 1
1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
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 tru d c o e best my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co ance " I Pertinent vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Keith J.Farnham LICENSE# 11601 SIGNATURE
MPS JP❑ CORPORATIONO# 3698C PARTNERSHIPS LLC❑#
COMPANY NAME South Shore Heating&Cooling ADDRESS 57 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL info@southshoreheatingcooling.com
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