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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
a;:� - CITY I � G '� .- _ 1 MA DATE' 3/I I PERMIT# NN)P /�v- q
JOBSITE ADDRESS IGII
L, 1(1'! . ,. LtwitQ , ( OWNER'S NAMES �)C1/4 1'1113 \+jC1``
OWNER ADDRESS ,1 L 1. ..... _ , b5, -. `alk3 I TEL ` ' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 171 EDUCATIONAL [- RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:[- REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB —
") CROSS CONNECTION DEVICE s (—
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM —
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET —
URINAL
_
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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 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 I AGENT I
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 thasac uall tts State
work andininstallations performed of the
hethe permit issued for this application will be i ce r h a�Perti provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Keith J.Farnham .,Tj LICENSE# 11601 SIGNATURE
JPLJ CORPORATION # C„ PARTNERSHIP#[ 1LLCLJ#
1
COMPANY NAME LSouth Shore Heating&Cooling,Inc._ ADDRESS 57 Whites Path
—
CITY South Yarmouth j STATE MA I ZIP 02664 1 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL
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