HomeMy WebLinkAboutBLDP-16-004586 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY MA DATE j_-- JI PERMIT#/o/ /r0-0°‘15 0
JOBSITEADDRESS 74' 11416 �,OWNER'SE
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P OWNER ADDRESS I , .- . . _ _ T �{�1 gde7 .._'FAX i 1
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL TJ RESIDENTIAL V
PRINT
CLEARLY NEW: RENOVATION: V REPLACEMENT:L PLANS SUBMITTED: YES NOEl ; +
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ,----1, ,r _ .— —• _—,4--.---1
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CROSS CONNECTION DEVICE _�
DEDICATED SPECIAL WASTE SYSTEM __
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM �_
DEDICATED WATER RECYCLE SYSTEM i'
DISHWASHER ter. -
DRINKING FOUNTAIN
FOOD DISPOSER 1=- _...&_, ---- - ;---/—,----
FLOOR/AREA DRAIN _ _
INTERCEPTOR(INTERIOR)
KITCHEN SINK __. ___
LAVATORY ._ _ 1.
ROOF DRAIN I
SHOWER STALL1137 .
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SERVICE/MOP SINK
TOILET r C', _
URINAL _ �
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES L._. _j t
WATER PIPING __ - Ir.
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 ® 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; pWNER 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 urate 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' ' 'th Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME i Phillip Durfee LICENSE#i 13774 1 SIGNATURE
MP i JP CORPORATION # 1PARTNERSHIPD#[ LLC # 3152
COMPANY NAME Durfee Plumbing&Heating LLC I ADDRESS 2A Huntington Ave.
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CITY South Yarmouth STATE Mq ZIP 102664 TEL 508-619-3078
FAX 508-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;joy@durfeeplumbing.com
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