HomeMy WebLinkAboutP-13-516 1:::, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�9 JOBSITE ADDRESS Ibey 2 t uf1Z-.S 7Z OWNER'S NAMEE4Z4I A_ 2)/„o c• I
P OWNER ADDRESS SA-040..— TEL 6003ge//ojFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:Q RENOVATION:❑ REPLACEMENT:fir PLANS SUBMITTED: YES Q NOQ
FIXTURES 1 FLOOR-. BSM '1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i ' `
CROSS CONNECTION DEVICE?k/L`G . I. _ _
DEDICATED SPECIAL WASTE SYSTEM I ' •I
DEDICATED GASIOIUSAND SYSTEM ” I
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 9 I r I j
DEDICATED WATER RECYCLE SYSTEM ' I! ! I '[
DISHWASHER i
DRINKING FOUNTAIN
FOOD DISPOSER w
FLOOR I AREA DRAIN i
INTERCEPTOR(INTERIOR)
KITCHEN SINK W
LAVATORY
ROOF DRAIN
SHOVVER STALL
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SERVICE/MOP SINK 1 r I
TOILET
URINAL
WASHING MACHINE
WATER HEATER ALL TYPES
CONNECTION
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WATER PIPING
OTHER r
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 0 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.
CHE7:O : 0 E ❑ AG ❑
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 a to to t e best of nowledge
and that all plumbing work and Installations performed under the permit Issued for this applicatlorr(will be In compliance t II P ne provisl of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Stephen A.Winslow LICENSE# 12298 SIGNATURE
MP JP CORPORATIONO# 3281C PARTNERSHIP 0# LLC®#
COMPANY NAME E.F.Winslow Plumbing&Heating Co.,Inc. ADDRESS 8 Reardon Circle
CITY South Yarmouth STATE MA ZIP 02664 1 TEL 508-3947778
FAX 508-394-8256 I CELL N/A EMF accountspayabtedptislo m
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ROUGH PLUMBING INSPECTION NOTFC FELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTER
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THIS APPLICATION SERVES AS THE PERMIT 0 0
- - FEE: S PERMIT#_ - .. . .
FLAN REVIEW NOTES
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