HomeMy WebLinkAboutBLDP-19-001835 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Y` Southarmouth 9/14/2018 �d g7
=•=,.1;�_a CITY/TOWNMA DATE PERMIT# I?"��
JOBSITEADDRESS 44 Davis Road OWNER'S NAME Letourneau
p , OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL ❑ RESIDENTIAL EI
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES Cl NO[1
FIXTURES 1- FLOOR-) BSM 1 2 3 4 5 6 7 8 9 10 41 12 13 14
BATHTUB
• CROSS CONNECTION DEVICE 1
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
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
• SHOWER STALL
' SERVICE 1 MOP SINK
TOILET
URINAL
_WASHING MACHINE CONNECTION
• WATER HEATER ALL TYPES 1
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 [cYNO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY La 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
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. tedy. _
PLUMBER-GASFITTER NAME LICENSE# ,a GIVATLIgg•
Andrew Levesque PL15162
MP MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC wilt 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 andyAhphcllc.com
it