HomeMy WebLinkAboutBLDP-19-000729 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
`. CITY k West Yarmouth MA DATE 7/12/18 PERMIT#i/ P'/?�� "��
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JOBSITE ADDRESS 193 Jefferson Ave. OWNER'S NAME Crystal Maddalena
OWNER ADDRESS 136 Hombre Circle, Panama City,FL 32407 TEL 508 360 3263 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL [J RESIDENTIAL
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CLEARLY NEW: 71 RENOVATION: REPLACEMENT:71 PLANS SUBMITTED: YES N0J
FIXTURES Z FLOOR-* 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 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 t1c,. 1
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 D NO ID
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 bi 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 tr and a,icur e to s of knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co iance,9 ith e inent provi on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t1
274.4-
PLUMBER'S NAME Keith J.Farnham LICENSE# ; 11601 S ATURE —
MP17i JP CORPORATION#F 3698C PARTNERSHIP LI# LLCI _i#r 1
COMPANY NAME South Shore Heating&Cooling, Inc. 1 ADDRESS 57 Whites Path
CITY;South Yarmouth STATE L MA I ZIP 02664 TEL 508-398-6901
FAX 508 760 2681 CELL EMAIL
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