HomeMy WebLinkAboutBLDP-19-0005654 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
.-u�l";) CITY yarmouthport MA DATE 3/8/2019 PERMIT#/ 0'?—OG3 t f
JOBSITE ADDRESS 53 arthur lane OWNER'S NAME eleanor krake
P OWNER ADDRESS TEL 3629661 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I
CROSS CONNECTION DEVICE �!
DEDICATED SPECIAL WASTE SYSTEM
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DEDICATED GAS/OIUSAND SYSTEM I p
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 11111
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN N F I I J 1I l
FOOD DISPOSER
FLOOR/AREA DRAIN J 1
INTERCEPTOR(INTERIOR) I !I
KITCHEN SINK
LAVATORY 1,
ROOF DRAIN
SHOWER STALL I 1
SERVICE/MOP SINK
TOILET I
URINAL
WASHING MACHINE CONNECTION I II I
WATER HEATER ALL TYPES
WATER PIPING
OTHER 1it I
I I I � 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❑ 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Keith J.Famham LICENSE# 11601 SIGNATURE
MP❑ JP El CORPORATION # 3698C PARTNERSHIP❑# 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
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