HomeMy WebLinkAboutBLDP-22-007309 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
a� ��� CITY IYARMOUTH
( -, I MA DATE 16/21/22 I PERMIT# BLDP-22-007309
=� / JOBSITE ADDRESS 1311 GREAT ISLAND RD I OWNER'S NAME ISAFRAN EDWARD H
P OWNER ADDRESS ISAFRAN HARRIET 37 BARNEY HILL RD WAYLAND,MA 01778-3601 I TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑
PRINT RESIDENTIAL El
CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURFS • FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER 1
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 1 2
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER -
WATER PIPING
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
YES❑ 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.
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 'Wellington Farias I LICENSE11)5949 I
SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I I
I LLC ❑#
COMPANY NAME 'Wellington Plumbing&Heating,Inc I ADDRESS 171 Vernon St
CITY 'Rockland
I STATE 'MA I ZIP 102370 I TEL 17815897578
FAX I I CELL I I EMAIL '
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