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HomeMy WebLinkAboutBLDP&G-19-002426 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK et ems". CITY I South Yarmouth MA DATE 10/16/2018 PERMIT#/9/ -er) 096 JOBSITE ADDRESS 1198 Great Western Road OWNER'S NAME Jacqueline&Edmund Skulte _---- OWNER ADDRESS 198 Great Western Road v TEL 6175496587 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL _J EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:C REPLACEMENT: v PLANS SUBMITTED: YES j_I NO{71 FIXTURES 7. FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 4 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 q ROOF DRAIN ._. SHOWER STALL SERVICE/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 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 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. e _ PLUMBER'S NAME Phillip Durfee LICENSE# 13774_ SIGNATURE MP JP I CORPORATION Pi# PARTNERSHIP # LLC / # 3152 COMPANY NAME Durfee Plumbing&Heating LLC ;ADDRESS 12 American Way Unit 1 } CITY` South Dennis STATE MA " ZIP 02660 TEL 508-619-3078 FAX 508-258-0592 CELL 508-801-8004 J EMAIL phis@durfeeplumbing.com;sales@durfeeplumbing.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ==d u . *Yew CITY South Yarmouth MA DATE 10/16/2018 PERMIT# P J�`��','�"/ (' JOBSITE ADDRESS 198 Great Western Road OWNER'S NAME Jacqueline&Edmund Skulte OWNER ADDRESS 198 Great Western Road TEL 6175496587 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS-4 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 a a r to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp) t II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Phillip Durfee LICENSE# 13774 SIGNAT 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 t r'N- l/'i