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SJ, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
SW ciw r1/9r/n 02/V - I MA DATE I d6'0 7•/41 PERMIT# P14— r6Y
JOBSITE ADDRESS I ZZL Vpj/C/L �aITBL4CI OWNER'S NAME !t///f/pyi,g } (�,i
tk P OWNERADDfjES$)&pi ` TEL > +, y', AX
TYPE OR OCCUPANCY Yep COMMERCIA /Li EDUCAT NAL �/
PRINT 0 RESIDENTIAL a�� .
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO in
FIXTURES 1 FLOOR— 85M 1 1 2 i 3 4 5 6 7 8 9 10 1, 11 12 J 13 1 14
BATHTUB
MCROSS CONNECTION DEVICE v
DEDICATED SPECIAL WASTE SYSTEM ,
DEDICATED GAS/OIUSAND SYSTEM
q DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM ii i
DEDICATED WATER RECYCLE SYSTEM II
,..,...
DISHWASHER _
DRINKING FOUNTAIN H_
FOOD DISPOSER
FLOOR/AREA DRAIN t
INTERCEPTOR(INTERIOR) I _ I ,
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET .
URINAL
WASHING MACHINE CONNECTION •
WATER HEATER ALL TYPES I
WATER PIPING -1
OTHER ,
INSURANCE COVERAGE:
I have a current Jiability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO Q
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �• "'
LIABIUTY INSURANCE POLICY Q 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.
CHEC INE ONLY: OWNER W/ 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 an• •-•r. . to the •• t of my kno
and that all plumbing work and installations performed under the permit issued for this application will be in compliance vn -ertine• p • i Sion of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A WINSLOW I LICENSE# 12298 SIGNATURE '
MPD JP❑ • CORPORATIOND# 3281 PARTNERSHIP❑# LLC❑#_�� A
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CCaJ ADDRESS 8 REARDON CIRCLE .^a Iy42
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CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 `A' t, :, Y
FAX 508-394-8256 CELL EMAIL I ACCOUNTSPAYABLE@EFWINSLOW.COM Ce �.\ a;i
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ROUGH GASINSPECTION NOTES MIS PACE FOR INSPECTOR USE ONLY • FINAL INSPECTION NOTES
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Yes No j, , •
THIS APPLICATION SERVES AS THE PERMIT ID
FEE: PERMIT#
PLAN REVIEW NOTES
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