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Home My WebLink AboutBLDP-17-005915 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y`� mantes, 5 ��'� ° i' mfl�1� CITY OV 'I __. .__ MA DATE I A PERMIT# t /)-/7- g�t�S" JOBSITE) 10IiDRESS tiCk, Rd Q u" 'tY, I OWNER'S NAME bu 14- 4 wt POWNER ADDRESS TEL •1y• 644,p1FAXr i TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL L PRINT _ CLEARLY NEW:fa._i RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES L-1 NOD FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ��..._._ CROSS CONNECTION DEVICE iJI DEDICATED SPECIAL WASTE SYSTEM rT— 11--_ 'r DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM i ---— DISHWASHER DRINKING FOUNTAIN II I FOOD DISPOSER j FLOOR/AREA DRAIN 1 INTERCEPTOR(INTERIOR) �' KITCHEN SINK wI LAVATORY L_ ROOF DRAIN C __ SHOWER STALL T �_ SERVICE/MOP SINK TOILET L URINAL r _ tI, WASHING MACHINE CONNECTION L 11— WATER HEATER ALL TYPES r 1 I WATER PIPING OTHER ___ _ _ _:.__ w 1 ) INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES a NO IJ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY..!, 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 `, .1 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 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 cplia ce 'h ertinent ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r PLUMBER'S NAME Keith J.Famham LICENSE# 11601 SIGNATURE MPH,J JP CORPORATION(# it'? C IPARTNERSHIPD# LLC[ #I COMPANY NAME! South Shore Heating&Cooling,Inc. ADDRESS 57 Whites Path CITY South Yarmouth 7 STATE MA I ZIP 02664 : TEL 508-398-6901 • FAX 508-760-2681 CELL j EMAIL — // ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES _ s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS WORK • 4rtffi" - CITY I I MA DATE PERMIT# I/-cif'/7_od j�/) JOBSITE ADDRESS 1k ��xl/Iti� �)/\ OWNER'S NAMEriz—becA-- (kvv! P OWNER ADDRESS xa.. TEL 50g .41f,r- '1FAXL ., _µA TYPE OR OCCUPANCY TYPE COMMERCIALLJ EDUCATIONAL T RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:REPLACEMENT: PLANS SUBMITTED: YES , NOL. APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE j DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT 'Ir TEST UNIT HEATER I,__ L UNVENTED ROOM HEATER _ 1;_ _ ~ WATER HEATER OTHER 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 v_ OTHER TYPE 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 ; , '• 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 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 comp iance yrith Pe t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME[Keith J.Farnham LICENSE#E 11601 SIGNATURE MP cE MGF „] JP JGF L LPG'[J CORPORATION`'''# a i C, ; PARTNERSHIP #[. LLC COMPANY NAME:;South Shore Heating&Cooling, Inc ADDRESS 57 White's Path ro_ _ ____. CITY South Yarmouth _v_ 1 STATE' MA ZIP 02664 TEL 508-398-6901 9 FAX 508-760-2681 CELL' ��EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# vlif/' PLAN REVIEW NOTES v L • r