HomeMy WebLinkAboutBLDP-18-006115 , , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_ CITY / 'Man_ ,.__.. MA DATE Y/1O/f I PERMIT#/3ADP d106116
JOBSITE ADDRESS 3-23 p OWNER'S NAMEI �S v�'1( a1/!
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P OWNER ADDRESS POBox_._62[ 5- l�► �1,f 0244 y' TELlo -37 - y JFAX . _
TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL 0 RESIDENTIAL L�I
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CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:Fir PLANS SUBMITTED: YES 0 NOE
FIXTURES I FLOOR-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB — ®' I _ _® _.- j
CROSS CONNECTION DEVICE _ II i__ _
DEDICATED SPECIAL WASTE SYSTEM ( _ n_ _.
DEDICATED GASIOIUSAND SYSTEM _ _MI IIIM
DEDICATED GREASE SYSTEM MIS I M.
DEDICATED GRAY WATER SYSTEM Inn ® M' MIMT M
DEDICATED WATER RECYCLE SYSTEM f N
DISHWASHER T
DRINKING FOUNTAIN FOOD DISPOSER III=1I
FLOOR AREA DRAIN I ! MINI i
INTERCEPTOR(INTERIOR) MI, IMIUMBNIII
KITCHEN SINK I MI.- WAIIROOF DRAIN h I I __
SHOWER STALL mum= ®_
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•• SINK _MAIMINIMI 1.11111.1111.1111 Immo 1 1 — glinliMIME=11111111
r__ WASHING MACHINE
• . __ ®_a-. WATER HEATER ALL TYPES 1 ;
OTHERWATER PIPING ,
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I _ I I own ®_
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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 0 NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY BOND
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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 D 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 n accura st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co wi all Pertin provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBERS NAME Keith,J.Farnham 1 LICENSE# 11601 SIGNATURE
MPO JP O CORPORATION 0# 3698C PARTNERSHIPQ# y LLC #
COMPANY NAME South Shore Heating&Cooling, Inc. 1 ADDRESS 57 Whites Path
CITY South Yarmouth STATE I MA ] ZIP 02664 TEL 508 398-6901
FAX 508-760-2681 CELL EMAIL II a