HomeMy WebLinkAboutBLDP-18-004223 [ ,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'.�=Iff_a CITY�South Yarmouth u MA DATE 01/18/2018 ;PERMIT# et 1.il -/f c1
JOBSITE ADDRESS 137 Wolfson Road OWNER'S NAME Alex Chuprin
POWNER ADDRESS 4 37 Wolfson Road ,_ _ — ; TELL6177673054 ._ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ,., EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES fl NO
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
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER - --
DRINKING FOUNTAIN r w
FOOD DISPOSER ;
FLOOR/AREA DRAIN — _ ___
INTERCEPTOR(INTERIOR) _v.
KITCHEN SINK L
4
LAVATORY _____
ROOF DRAIN _
SHOWER STALL _
SERVICE/MOP SINK
TOILET
URINAL
_r
WASHING MACHINE CONNECTION
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WATER HEATER ALL TYPES y
WATER PIPING --'' _ —
OTHER Boiler 1 — —
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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 v OTHER TYPE OF INDEMNITY El 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 0 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 e 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 all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Phillip Durfee LICENSE#'13774 SIGNATURE
MP / JP _I CORPORATION # PARTNERSHIP# LLC i # 3152
COMPANY NAME Durfee Plumbing&Heating LLC .ADDRESS 12 American Way Unit 1
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CITY South Dennis STATE MA ] ZIP 1 02660 TEL 508 619 3078
FAX F608-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;sales@durfeeplumbing.com
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