HomeMy WebLinkAboutBLDP-16-005074 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
:.174, s CITY_ 1 rr Ov '1 _ I MA DATE - PERMIT# �DP/b-'4� 1/
YJOBSITE ADDRESS LGI {fjt ; OWNER' E"
POWNER ADDRESS I m, _. . _ 1 TEL 7`7i FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 1] EDUCATIONAL J RESIDENTIAL V
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES NO IP�J
FIXTURES 7 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE i-Vr
DEDICATED SPECIAL WASTE SYSTEM I
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM s '' _
DEDICATED GRAY WATER SYSTEM �I— ,I -
DEDICATED WATER RECYCLE SYSTEM —`°
DISHWASHER
DRINKING FOUNTAIN u '
FOOD DISPOSER ,f I
FLOOR/AREA DRAIN r
INTERCEPTOR(INTERIOR) jl {
KITCHEN SINK
LAVATORY r r -II _
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ROOF DRAIN
SHOWER STALL 1 i�
SERVICE/MOP SINK _-1_ _
TOILET MIL
URINAL ------4— li ti
WASHING MACHINE CONNECTION '
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WATER HEATER ALL TYPES _ i
WATER PIPING _
OTHER
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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 i OTHER TYPE OF INDEMNITY 0 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 t and a rate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c n th all inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Phillip Durfee ,LICENSE# 13774 SIGNATURE
MP JP A CORPORATION # PARTNERSHIP____,#, LLC v # 3152
COMPANY NAME[Durfee Plumbing&Heating LLC ADDRESS 2A Huntington Ave.
CITY[uth Yarmouth STATE DTI ZIP '02664 TEL i 508-619-3078
FAX D08-258-0592 CELL 508-801-80 EMAIL [hil@durfeeplumbing.com;joy@durfeeplumbing.com
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