HomeMy WebLinkAboutP-14-403 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I_=• CITY I Vatn ez4 ' Ger I MA DATE 1//-c-20 73 I PERMIT# Pig— Ya.-/
JOBSITE ADDRESS I hi-7 a'Kite- 5-/-: I OWNER'S NAMEI 4-4 it,,&_-- I
P OWNER ADDRESS I i7 Ce'*r 5 I,TELI , e2—s'o5y IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL.❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:I PLANS SUBMITTED: YES 0 NO❑
tO FIXTURES 1 FLOOR—, BSM J 1 4 2 3 1 4 1 5 j 6 1 7 6 9 I 10 I 11 ) 12 4 13 4 14
BATHTUB
CROSS CONNECTION DEVICE a
DEDICATED SPECIAL WASTE SYSTEM ...a...
DEDICATED GAS/OIUSAND SYSTEM al
' ' DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM r
DEDICATED WATER RECYCLE SYSTEM l .
rTDISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR!AREA DRAIN
fl INTERCEPTOR(INTERIOR) A
KITCHEN SINK
V LAVATORY
ROOF DRAIN
SHOWER STALL
' •
SERVICE/MOP SINK
r
TOILET .
URINAL
WASHING MACHINE CONNECTION • '
A
WATER HEATER ALL TYPES 1
WATER PIPING
OTHER b.
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGI;Icft.1}2. ((ES + O'EI
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IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL *•
LIABILITY INSURANCE POLICY❑+ OTHER TYPE OF INDEMNITY 0 BOND ❑ t'--'- - F 3
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requireby Chapter.142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement. �By '' '`x''3.76_, Vi yO 0
CHECK • OWN R 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 ccu to to the 1 of my kn ge
and that all plumbing work and Installations performed under the permit Issued for this application will In compliance Pertine t provision o th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAMEI STEPHEN A WINSLOW LICENSE# 12298 SIGNA RE
MPD JP • CORPORATION D#3281 PARTNERSHIP❑# LLC❑#) J
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CCJ ADDRESS 8 REARDON CIRCLE
,
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394.7778
FAX 50&394.8256 I CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM .i
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ROUGH GAS INSPECTION NOTES , THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT It
PLAN REVIEW NOTES
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