HomeMy WebLinkAboutBLDP-20-006266 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
rf/E=er West Yarmouth 6/10/2020 �j 0
e+It_i-s' CITY/TOWN MA DATE PERMIT �•l�Iz�Q� '•`"
• JOBSITEADDRESS 61 Bayberry Road OWNERS NAME Ripley
p OWNER ADDRESS TEL 508-430-0771 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW:El RENOVATION:[XI REPLACEMENT:❑ PLANS SUBMITTED: YES El NO IX
FIXTURES 1 FLOOR—I BSM 1 2 3 4 51 6 7 6 9 10 11 12 13 14
BATHTUB 1
• 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
F.,
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 1 I
ROOF DRAIN
SHOWER STALL 1
' SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING -
OTHER
Underground rough only
INSURANCE COVERAGE
1 have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES L YNO ❑ ,
I IF YOU CHECKED YES,PLEASE ININCATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ ' OTHER TYPE INDEMNITY El BOND Q
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
I hereby pertify 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.
PLUMBER-GASFITTER NAME �iAT.0 •
Andrew Levesque LICENSE# PL15162 G
MP g MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC g# 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(hphcilc.com kecia@hphcllc.com
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