HomeMy WebLinkAboutBLDP-19-006160 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-
svkfi CITY South Yarmouth ' MA DATE 4/15/2019 J PERMIT#/, 9-✓'-
JOBSITE ADDRESS 25 Vine Brook Road OWNER'S NAME Demitri Riskal
OWNER ADDRESS 2 Vine Brook Road TEL 339.970.1133 FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL 9 EDUCATIONAL '_j RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: � 4 PLANS SUBMITTED: YES NO
FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM
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
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1 u_
WATER PIPING
OTHER d_
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 .ccura - to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compf. i : I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Phillip Durfee LICENSE#1.13774, SIGNATURE
MP JP _ CORPORATION # PARTNERSHIP # j 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
3/4
FAX 508-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;sales@durfeeplumbing.com