HomeMy WebLinkAboutBLDP&G-19-006890 •
' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
s. r' fif CITY • 1\ 21 y\ l,`, I MA DATE �_,= -6D—\ CI\ PERMIT#/34O/d a070
JOBSITE ADDRESS OWNER'S NAME
POWNER ADDRESS L S,,`1. TEL _ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL _..j EDUCATIONAL 1 RESIDENTIAL DC
PRINT
CLEARLY NEW: RENOVATION:_. REPLACEMENT: a PLANS SUBMITTED: YES L NOI I
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB [ IF
CROSS CONNECTION DEVICE L.
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM _
DEDICATED GREASE SYSTEM _ - [ —
DEDICATED GRAY WATER SYSTEM —fir
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ..i.___
DRINKING FOUNTAIN 1---- [ __
FOOD DISPOSER __L._ !1 ,;
FLOOR/AREA DRAIN I _I___._ f
INTERCEPTOR(INTERIOR) -1F -IF- -IF--
KITCHEN SINK IL _-1, )
LAVATORY
IL . I
ROOF DRAIN c
SHOWER STALL
SERVICE/MOP SINK
TOILET = A t I
URINAL --L 1
WASHING MACHINE CONNECTION --II I'
WATER HEATER ALL TYPES
WATER PIPING
--- ""
OTHER _ ll
f
+INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES n NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY[ -1 OTHER TYPE OF INDEMNITY I I BOND U
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 I I AGENT Li
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 d acc rate o y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co n e all i ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
PLUMBER'S NAME Keith J. Farnham LICENSE# ' 11601 SIGNATURE
MPL I JP CORPORATION ,1# 3698C PARTNERSHIP # N!LC__J#
COMPANY NAME South Shore Heating&Cooling ADDRESS 57 Whites Path
CITY South Yarmouth I STATE MA ZIP 02664 i TEL;508 398 6901
FAX C08-760-2681 I CELL r I EMAIL r .. -
- `
'r-- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r=_�>�C /Qp
. _i1�(s.- CITY L`41 �►.'�' `N\Q��
MA DATE�-3�—\ c -PERMIT# 4O�/F-'�4Ol6
JOBSITE ADDRESS S Q iiiArk,N 't4 OWNER'S NAME 1 DcaN -�
GOWNER ADDRESS I S�.,y 1 TELL _ - FAX J
TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL ® RESIDENTIAL 6j
PRINT
CLEARLY NEW:L_j RENOVATION:El REPLACEMENT:1210 PLANS SUBMITTED: YES n NO
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER _--- _
CONVERSION BURNER _ _ I
COOK STOVE - -- 1 I
DIRECT VENT HEATER ' 1 I
DRYER
FIREPLACE
FRYOLATOR
FURNACE r _ i�.
GENERATOR r
GRILLE
INFRARED HEATER
LABORATORY COCKS _
MAKEUP AIR UNIT
OVEN a 1 il
POOL HEATER 1 11
ROOM/SPACE HEATER �`
ROOF TOP UNIT ---
TEST .
UNIT HEATER it 1
UNVENTED ROOM HEATER
WATER HEATER 'L
OTHER � � '
�,
L -
__
_ ,
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES , NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [] OTHER TYPE INDEMNITY j j BOND L
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 Li
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 accurati to th best o/ knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia th a Perti en r ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,,, —c,
PLUMBER-GASFITTER NAME[Keith J. Farnham LICENSE#I 11601 GNATURE
MP , MGF I I JP Q JGF Lv LPG' ] CORPORATION D#L3698C PARTNERSHIP[DO .J LLC 0# 1
COMPANY NAME:I South Shore Heating&Cooling, —1 ADDRESS F7 White's Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 5 08-398-6901
nn.
FAX E08-760-2681 CELL EMAIL tnp-- e [j�(-- ^ -I' !1' cQGk 11 \u -c.c
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