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HomeMy WebLinkAboutP-14-372 v _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =i= • CITY I Yr9r0'14tiVh IMA DATE /1. SO. ,!3 RMITap4 - 372.. JOBSITE ADDRESS 1 2374e4124 rete/y, I OWNER'S NAMEI Jb N dei I P OWNER ADDRESS I aky,Q d yi----) I TO L5M5rA1 y7e5/ !FAX' TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL 0 RESIDENTIAL PRINT N CLEARLY NEW:0 RENOVATION:Q REPLACEMENT:? PLANS SUBMITTED: YES❑ NO,7 N FIXTURES 1 FLOOR-. BSM j 1 j .2 j 3 4 j 5 j e j 7 j a J 9 j Io ] 11 j 12 j 13 j 14 • N BATHTUB N CROSS CONNECTION DEVICE (�,J DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM 1 DEDICATED GRAY WATER SYSTEM ' Q DEDICATED WATER RECYCLE SYSTEM J DISHWASHER DRINKING FOUNTAIN '4 FOOD DISPOSER ' FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK , LAVATORY V ROOF DRAIN SHOWER STALL A SERVICE/MOP SINK TOILET URINAL I WASHING MACHINE CONNECTION ■�� • `WNEkPANt1LALL 7YP © r 9 r WEkPI NG I/In�v/& �j< v OT ER .1�. I NOV 2n 2013 •• , , n UUAL A Set:r1 4 77i - INSURANCE COVERAGE: e' no rhitriiiiiiiricepolicy or its substantial equIvaleM which meets the requirements of MGL Ch. Y C •• Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -- .,:• LIABILITY INSURANCE POLICY Q 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. CHECK s.• : . 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 a.- ra to the b of my knoyl e end that all plumbing work and installations performed under the permit issued for this application will be in compliance with •e .I 1 Ian of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME'STEPHEN A WINSLOW (LICENSE#[12298 SIGNATURE MPQ JP • CORPORATION0# 3281 PARTNERSHIPD# LLCD#I I COMPANY NAMEI E.F.WINSLOW PLUMBING&HEATING CCS ADDRESS 8 REARDON CIRCLE I CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508.394.7778 - FAX 508-3948256 CELL j EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM :r < . r ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES • + Yes No ' THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: S REMITS i zi PLAN REVIEW NOTES J