HomeMy WebLinkAboutBLDP-19-004885 al. 4 c-- -c----1--
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: ,a,.... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_4; CITY south yarmouth(c4.,,,
MA DATE 2/12/2019 PERMIT#/i 2Pft 0 7gr7
JOBSITE ADDRESS 175 beacon st OWNER'S NAME dave witter
OWNER ADDRESS TEL 5183668209 FAX L__J`
3 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES i FLOOR-4 , BSM i 1 2 3 4 5 6 7 18 9 10 11 12 13 14
BATHTUB
11Il
v,-� CROSS CONNECTION DEVICE J x I ' -
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DEDICATED SPECIAL WASTE SYSTEM 1 ji
DEDICATED GAS/OIL/SAND SYSTEM 1 1 U I 0 I
DEDICATED GREASE SYSTEM 11
DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM III1 I
DISHWASHER MI I
DRINKING FOUNTAIN I �� � _.� 1 __ _. -- J
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[-7r I 1 1 ii!
FOOD DISPOSER i p
FLOOR/AREA DRAIN U ll I
INTERCEPTOR(INTERIOR) ®1 I
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KITCHEN SINK iE
LAVATORY
1 I111
ROOF DRAIN U I, ii SHOWER STALL 1
SERVICE MOP SINK ,
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TOILET I
URINAL
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WASHING MACHINE CONNECTION I l
WATER HEATER ALL TYPES- x (� t
'fiR PIPING
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OTHER - —— - � �I INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q 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:r OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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i hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate best of my, nowledge
i and that all plumbing work and installations performed under the permit issued for this application will be in com " `ce wi all ins provisi of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBERS NAME Keith J.Famham LICENSE# 11601 ISIG ATURE
i MP❑ JP El CORPORATION❑# 3698C PARTNERSHIP❑#- ILLC❑#
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 Ink) at ("�}} r� iv-[,Willii cJC kt Cj ,CCS�
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