HomeMy WebLinkAboutBLDP-16-004102 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
„ CITY I yoirY 1214 th vorr I MA DATE I II— I IY PERMIT# 04/ -/IP`"6' /C'
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JOBSITE ADDRESS ca r t OWNER'S NAME ff
POWNER ADDRESS , . _ TEL / 0 FAXI 1
TYPE OR OCCUPANCY TYPE COMMERCIAL ! EDUCATIONAL '11 RESIDENTIAL Er
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CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO2
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _.__. _.._.._., ._,.
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CROSS CONNECTION DEVICE M. — MI IIIIIIIMIIMMIIIII MEM_
DEDICATED SPECIAL WASTE SYSTEM am—mil— gum ®
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DEDICATED GAS/OIL/SAND SYSTEM MI�����
DEDICATED GREASE SYSTEM MIIIII
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DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM ill
DISHWASHER _----__--1111111111111
DRINKING FOUNTAIN IIJ[. 1 --__WM
FOOD DISPOSER
FLOOR/AREA DRAIN II
INTERCEPTOR(INTERIOR) 11 II IIIIII
KITCHEN SINK morammoimmuisommiminum
LAVATORY 1111111 —__—min �.
ROOF DRAIN 11 ■III Mill■
SHOWER STALL
SERVICE/MOP SINK 11.11111111111
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TOILET M_U® EllMIN
URINAL �—NM 11111111111
WASHING MACHINE CONNECTION NM 011111
WATER HEATER ALL TYPES --®
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WATER PIPING NZ 111 III■■ ®
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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 ' NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY v OTHER TYPE OF INDEMNITY ® BOND D
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 INLY• /OWNER AGENT
SIGNATURE OF OWNER OR AGENT ,
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I hereby certify that all of the details and information I have submitted or entered regarding this application are 4 ccurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in •, .-e 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER'S NAME LPhillip Durfee 'LICENSE# 3 13774 , SIGNATURE
MPF JPD CORPORATION It/ PARTNERSHIP # LLC # 3152
COMPANY NAME Durfee Plumbing&Heating LLC I ADDRESS 12A Huntington Ave.
CITY South Yarmouth STATE MA I ZIP L02664 I TEL 508-619-3078 I
FAX 508-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;joy@durfeepiumbing.com
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