HomeMy WebLinkAboutBLDP-19-005757 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS 39 Bernard Street 1 OWNER'S NAME John Zinck
OWNER ADDRESS 39 Bernard Street ; TEL'6178870848 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL fl EDUCATIONAL RESIDENTIAL v_I
PRINT
CLEARLY NEW: 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 w..
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM s;
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER --
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET t ;
URINAL
WASHING MACHINE CONNECTION If
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 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 apc'accur to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in COMpiff Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Phillip Durfee _ _ 'LICENSE# 13774 1 SIGNATURE
MP JP _ ` CORPORATION # PARTNERSHIP(- # LLC # 3152
COMPANY NAME Durfee Plumbing&Heating LLC ADDRESS 12 American Way Unit 1
CITY South Dennis _STATE MA ZIP 102660 TEL 508-619-3078
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FAX 508-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;sales@durfeeplmbing.com