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HomeMy WebLinkAboutP-14-035 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK fi N awl rtt-rru Oti 1 I MA DATE O7 ea -el PERMIT# P T J I JOBSITE ADDRESS Z/ h l OWNER'SNAMEI y � � A/( `�/' J�4(� D N 1 Wil` OWNER ADDRESS I 6, Y117/1l, `,`V(h) ,. I TELI6/7 75s' IFAXl I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ] • • - ^,' CLEARLY PRINT NEW:0 RENOVATION:0 REPLACEMENT:[g 7 PLANS SUBMITTED: YES 0 NO 1i[a FIXTURES 1 FLOOR-, j BSM 1 1 2 1 3 1 4 5 6 1 7 1 8 1 9 1 10 1 11 I 12 13 14 '\ BATHTUB N CROSS CONNECTION DEVICE N DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ii DEDICATED WATER RECYCLE SYSTEM DISHWASHER i ^ r V_DRINKING FOUNTAIN FOOD DISPOSER -. - 'i1f r p lit, II,= 1� FLOORIAREADRAIN . INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY d h ROOF DRAIN - A , SHOWER STALL' A. SERVICE/MOP SINK TOILET • URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES - WATER PIPING OTHER i - r INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY a OTHER TYPE OF INDEMNITY 0 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' NNE N ' . : OWNER la AGENT VA SIGNATURE OF OWNER OR AGENT are true : • scour to to the • t of my know)=�.e I hereby certify that all of the details and Information I have submitted or entered regarding this application end that all plumbing work and Installations performed under the permit Issued for this application v.411 be In compliance ' I •ertine• provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `r PLUMBER'S NAME I STEPHEN A WINSLOW 'LICENSE# 12298 SIGNAT 'E MP JP E] • CORPORATION❑#13281 IPARTNERSHIP©#I ILLCC]#I__,__1 I COMPANY NAMEI E.F.WINSLOW PLUMBING 8 HEATING Ct ADDRESS 16 REARDON CIRCLE 7 CITY'SOUTH YARMOUTH . I STATE I MA 1 ZIP 102664 1 TEL 1508.394-7778 • .. . I FAX 1508-394.8258 1 CELL I 1 EMAIL 1 ACCOUNTSPAYABLE@EFWINSLOW.COM I — 4. i ... �: . i. r • • r l� _ 5 StLN M O3IA32I NV Id r' ` IF LWM3d $. 331 0 0 11WM3d 3H1 SY S3AM3S NOLLY3I1ddY SIHl r oN s0A j? Y" : - SaION NO1133dSNI'IVNLI A'JNO 3SO uctioadswl 2IOi 30Vd STILL S3.LON NOI.L03dSNI SVO H011011