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HomeMy WebLinkAboutBLDP&G-19-003899 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK E m.z CITY[-West Yarmouth ' MA DATE�2/2712018 PERMIT# � ���� /%`�G��?A? JOBSITE ADDRESS 1 Colburne Path OWNER'S NAME Robert Rich 1 OWNER ADDRESS 1 Colbume Path I TEL 7745351053 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL 'iJ RESIDENTIAL PRINT CLEARLY NEW:` RENOVATION: REPLACEMENT:fl PLANS SUBMITTED: YES 71 NO FIXTURES Z FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB y—_.. ., CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER s DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ;- "R INTERCEPTOR(INTERIOR) KITCHEN SINK ` LAVATORY _ __. ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION `i 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 Li 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 . rate to • •est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp) a '-rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME!Phillip Durfee 'LICENSE# 13774 I " SIGNATURE MP JP 1 CORPORATION # 1PARTNERSHIP # LLC / # 3152 COMPANY NAME Durfee Plumbing&Heating LLC ADDRESS 12 American Way Unit 1 CITY South Dennis I STATE MA ZIP 102660 TEL 1508-619-3078 FAX 508-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;sales@durfeeplumbing.com (._/ // • • yr, ,g:. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • ,. v'a,A1rV C� WM= CITY West Yarmouth MA DATE 12/27/2018 PERMIT# ,9 1'�.E j_C/C) 1 JOBSITE ADDRESS 1 Colburne Path OWNER'S NAME Robert Rich OWNER ADDRESS 1 Colbume TEL 7745351053 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ BOOSTER _ _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR 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 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 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 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 accyr toto a the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complirce ' ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Phillip Durfee LICENSE# 13774 SIGNATURE MP MGF JP JGF LPG' CORPORATION # PARTNERSHIP # LLC # 3152 COMPANY NAME: Durfee Plumbing&Heating LLC ADDRESS 12 American Way#1 CITY South Dennis STATE MA ZIP 02660 TEL 508-619-3078 FAX 508-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;sales@durfeeplumbing.com .".1,.dr- .1f _.4,,--"— _ _