HomeMy WebLinkAboutBLDP-18-0001052 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
k-sup= /�P 0 CITY[West Yarmouth I MA DATE 08/14/2017 PERMIT#/ 1T M/00,
JOBSITE ADDRESS 7 Florence Lane OWNER'S NAME acy Leonard
POWNER ADDRESS 7 Florence Lane _ TEL 6176784470 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 1. EDUCATIONAL RESIDENTIAL—1_
PRINT _
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES N01%j
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ,r----i
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER n_,
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN _
SHOWER STALL
SERVICE/MOP SINK a
TOILET
URINAL w.._a_
WASHING MACHINE CONNECTION II 1,1 5
WATER HEATER ALL TYPES 1 '
WATER PIPING h;; —_ -
OTHER =_ ,_ _
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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 i NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i OTHER TYPE OF INDEMNITY 0 BOND i i
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 tr 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 co p' with all Pertin ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Philli Durfee Ir—
P LICENSE# 13774 SIGNATURE
MP ' JP Ej CORPORATION # jPARTNERSHIPEJ#j LLC v # 3152
e._
COMPANY NAME Durfee Plumbing&Heating LLC __ ADDRESS 12 American Way Unit 1
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CITY'South Dennis STATE MA—' ZIP 102660 TEL 508-619-3078
FAX 508-258-0592 1 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;sales@durfeeplumbing.com
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