HomeMy WebLinkAboutBLDP-20-000505 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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11‘11-'7 CITY/TOWN SOUTH YARMOUTH MA DATE 7/23/19 PERMIT
s JOBSITE ADDRESS 17 CAPTAIN LOTH RO P ROAD
OWNER'S NAME FINN
P ' OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL gl
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CLEARLY NEW:® RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO
FIXTURES T FLOOR-r BSM 1 2 3 4 5 5 7 8 9 10 11 12 13 14
BATHTUB
• CROSS CONNECTION DEVICE •
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01L/SAND SYSTEM
DEDICATED GREASE SYSTEM •
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM •
DISHWASHER
DRINKING FOUNTAIN I4
FOOD DISPOSER _ _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK •
TOILET
URINAL
WASHING MACHINE CONNECTION 1 i
• WATER HEATER ALL TYPES
WATER PIPING 1 -
OTHER
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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 fi
LIABILITY INSURANCE POLICY RA' 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME Andrew Levesque LICENSE# PL15162 GNATU
MP V' MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC I2f# 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 andy(a7hphcilc.com
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