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1 ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_cul. CITY III rine)1/71-3 I MA DATEI A ' /•/=APERMIT# Ply- 01-11
t JOBSITE ADDRESS 127 9/4/61/4/.//714‘,/,/J OWNER'S NAMEI £� ,4j I
P OWNERADDRESS I e 3 /4i/Yfl/z � I TELI7/ +'ZIS.47pAX ,
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY FIXTURES 7 NEW:0
FLOOR—.
❑LI 1 REPLACEMENT: � s . �6 � � � 8 �PLANS SUeBMITTED�YES❑13
1qBATHTUB 1 1 JJ 11 4
CROSS CONNECTION DEVICE
\ DEDICATED SPECIAL WASTE SYSTEM •
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM v
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN e
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR ,
KITCHEN SINK
LAVATORY
ROOF DRAIN _
SHOWER STALL L `
SERVICE/MOP SINK
TOILET .
URINAL
WASHING MACHINE •ONNNFCTInu • •
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INSURANCE COVERAGE:
I By: rren ra i Ito insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES a NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 4• "'
LIABIUTY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
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 I • • OWN:R ❑ AGE, 1/
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. ,-• rate to a best of • edge
and that all plumbing work and installations performed under the permit Issued for this application will b In compliance 4,1. all Pe nest provlai. I e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME STEPHEN A WINSLOW LICENSE# 12298 SIGNATURE
MPS JP EJ • CORPORATIONO# 3281 PARTNERSHIP❑# LLCQ#I I
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING COS ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394.7778
FAX 508-394.8256 CELL 1 EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM I
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#L14213d $ :333
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