HomeMy WebLinkAboutBLDP&G-17-003070 /CsCih 41> () ' \
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
a"F1 CITY south yarmouth MA DATE 11-9-2016 I PERMIT# '--i?--13D.fdZ)
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JOBSITE ADDRESS C3 bannister In I OWNER'S NAME arthur coverly
POWNER ADDRESS I TEL 50g• '/t.f '{65, 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL E
PRINT
CLEARLY NEW: Li RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I--- --,r--, ,I---1I-I- ''--------1 7---'
CROSS CONNECTION DEVICE 'i
DEDICATED SPECIAL WASTE SYSTEM 1
DEDICATED GAS/OIL/SAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM ri,
DEDICATED WATER RECYCLE SYSTEM if----1" -
DISHWASHER _ _
DRINKING FOUNTAIN �- ii -.
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK L
LAVATORY
ROOF DRAIN r err
SHOWER STALL i 71
SERVICE/MOP SINK
•
TOILET i
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES FI_
I
WATER PIPING mil. L___.-
OTHER ,_
„__
L-. I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Fl OTHER TYPE OF INDEMNITY El 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 I I AGENT I I
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru n ai.etTraIrtb th best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co ' n e wi all Perti nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _
PLUMBER'S NAME Keith J.Farnham LICENSE# 11601 j SIGNATURE
MP /A JP❑ CORPORATION O# 3698C ,PARTNERSHIP❑# J LLC I-__# ___ _ I
COMPANY NAME LSouth Shore Heating&Cooling,Inc. I ADDRESS 57 Whites Path —
CITY South Yarmouth STATE MA ZIP 02664 I TEL 508-398-6901
FAX 508-760-2681 i CELL EMAIL _- _ ___ _________ 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1.7.13
®"1T=J CITY south yarmouth MA DATE 11-9-2016 PERMIT# i/W9/2"i
JOBSITE ADDRESS 3 bannister In OWNER'S NAME arthur coverly
GOWNER ADDRESS TEL 54- . 05$ 1FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: ._ REPLACEMENT: PLANS SUBMITTED: YES NOL]
APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER I _
WATER HEATER -IT
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 � 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 J
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 a . e to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli e / I rti nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE# 11601 j / SIGNATURE
MP . MGF JP® JGF LPGI CORPORATION 0# 3698C PARTNERSHIP OM_ LLC #
COMPANY NAME:LSouth Shore Heating&Cooling, Inc ADDRESS 57 White's Path
CITY South STATE MA ZIP 02664 ITEL508-398-6901
FAX 508-760-2681 CELL EMAIL
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