HomeMy WebLinkAboutBLDP-20-001638 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• w=v
=``'"'= cITY1roWN South Yarmouth MA DATE 9/23/2019 PERMn- 9-00l0g
• JOBSITEADDRESS 3 Stoney Hill Drive
OWNER'S NAME Nankov
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IX
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO
FIXTURES T FLOOR-6 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _
• CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND 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 1 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 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ,•
LIABILITY INSURANCE POLICY LI' OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:lam 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
t hereby certify that all of the details and Information I have submitted or entered regarding this application are hie and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application wal be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
4:9PLUMBER-GASFITTER NAME LICENSE# Ja Girl TA U - �
Andrew LevesquePL15162
MP MGF❑ JP LI JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP[]# LLC Rf# 3944
COMPANY NAME Harwich Port Heating&Cooling LLC ADDRESS 461 Lower County Rd
CITY Harwich-Port STATE MA ZIP 02646 TEL 508-432-3959
FAX 508-432-6075 CELL 508-958-4874 _ EMAIL andytV hphcilc.com
•
RECEIVED
U724 2419
DEPARTMENT t
BUILOING
�-- E