HomeMy WebLinkAboutBLDP&G-18-000477 ,^.ram'. f 1 ('' ‘,r L'c\f( t'd(�-/ `� :)D
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMI TO PERFORM PLUMBING WORK
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®. CITY I �y= c{"104/A MA DATE C007 PERMIT# I?SIP if-4°01/77
JOBSITE ADDRESS Soc __ _ 1 OWNER'S NAMER5 -c P'
POWNER ADDRESS v 1 TELI COW-3 V-O y( VFAX L 1
TYPE OR OCCUPANCY TYPE COMMERCIAL i.,1,1 EDUCATIONALosI RESIDENTIALIV
PRINT
CLEARLY NEW: ''' RENOVATION:El._ REPLACEMENT: PLANS SUBMITTED: YES 3.- NO5(
FIXTURES 7. FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE i
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM i
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM 1
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN '
INTERCEPTOR(INTERIOR)
KITCHEN SINK =
i
LAVATORY .1
ROOF DRAIN -1
SHOWER STALL -17 I
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES F
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
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 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 inp> ce w hhaerti provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME Keith J. Farnhamw LICENSE#[11601 SIGNATURE
MP i' JP`„ CORPORATION #i i C 3PARTNERSHIPU# LLCI,WI
COMPANY NAME South Shore Heating&Cooling, Inc. ;ADDRESS 57 Whites Path
CITY South Yarmouth I STATE MA ZIP 02664 J TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL 1�
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
I
.&`� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY j YCvnwct�,� µ MA DATE[O 4/7 J PERMIT# / 1-/9/)%2-OG0 977
JOBSITE ADDRESS= ��? pit ysarc FA OWNER'S NAME (57 y "
OWNER ADDRESS fr.,_ _____v _� . , __ ____ ]TEL 0,`391%-Cr6/I 7 FAX r7 _F
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL J RESIDENTIAL(t
PRINT r
CLEARLY NEW: RENOVATION:[1] REPLACEMENT:I vcf PLANS SUBMITTED: YES[7 NO -
APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER .,
BOOSTER ��
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
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DRYER i
FIREPLACE I _
FRYOLATOR -in
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
WATER HEATER
OTHER i m
INSURANCE COVERAGE _
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 ' 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 I_,,
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 comp iance with Pe • t
provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -"" `e—'
PLUMBER-GASFITTER NAME l Keith J.Farnham _J LICENSE#; 11601 SIGNATURE
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MP 121 MGF JP I I JGF[J„ LPG'J CORPORATION I' 1# ' ? `' ( PARTNERSHIP LJ#L - J LLC[I]# ,_
COMPANY NAME: South Shore Heating&Cooling, Inc ADDRESS 157 White's Path
CITY South Yarmouth : STATE` MA ZIP;02664 TEL' 508-398-6901
FAX°508 760-2681 CELL EMAIL
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II ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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