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HomeMy WebLinkAboutP-13-340 52 ( MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT'TO PERFORM PLUMBING WORK dr . _ � "CITY W MA DATEI //'zy'/Z_I PERMIT# PI3- j 3 `o •JOBSITE ADDRESS Z/ tSkl/ �/.1i vt I OWNER'S NAME *,-7)7,k// i�C P OWNER ADDRESS /,/J�l4.7/2 p,/S97 I TELA T/_7 Y(y9 IFAX TYPE OR OCCUPANCY TYPE , COMMERCIAL❑ / EDUCATIONAL 0 RESIDENTIAL I • PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:[s PLANS SUBMITTED: YES❑ NO© I FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB S a;SJ.a ME IMF. 011111 I:INMAN a M M CROSS CONNECTION DEVICE 1 IMMiN=IMM � � IIIIII MK MI NMI -6l DEDICATED SPECIAL WASTE SYSTEM non ,n'n,alas win a,iiimo ,aa as ism DEDICATED GAS/DIUSAND SYSTEM 111M 1=111111111111•1 DEDICATED GREASE SYSTEM NM IS MI NM W MO MI MO MI MI MI INN 1111111111 `_INMI�■r I11�Illi illlll��lM lM MIMI 1111111,111111I a �ONAIM �:�l 111110-111111111111111= DEDICATED GRAY WATER SYSTEM �,�, MI �„ DEDICATED WATER RECYCLE SYSTEM r „�'MI ME��J������� FOOD NM DISPOSER FOUNTAINDRINKING latSSI11.111.111111,M1111,111111•111111.111111,111111111111 DISHWASHER a �, FLOOR I AREA DRAIN IW IIIIIII�INK 111111 a aMN MI 5 5s al INTERCEPTOR INTERIOR 11.111,11.11I •1M1 S 11 ,NN MOTS MS ice,;. KITCHEN SINK SNMI:IMO MEII=a a,a a aa.a 1111M1 MN_ LAVATORY lilliallISM1111a.•11111111I11111111;Sisn1111111:a.MM ROOF DRAIN M MUM En M11111 MB MOM MIN MI I all NIS M_ SHOWER STALL MI MIN ;NM SER VICE/MOP SINK • _I5;1Min=INS NIB;a lISMK1 TOILET M: MI MINMINN a,aa URINAL• a a lIONSINI:a s1111111$111111 SIN , WASHING MACHINE CONNECTION SIIIIMINIM IMF NW,Illlll■IMIN';S ISIS S15 5 WATER HEATER ALL TYPES MI _M MN MN MIN NS 111111 a WATER PIPING la x,5,5 5_�i5 11111� OTHER i����SMBISS5, anaMMEI•IS� a ,:a MIS M_,I_,P:M1111111 . a a M MIS,M'MI"M'NS MISS a4- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES a NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW . LIABILITY INSURANCE POLICY 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. ' CHEC' ONE ONLY: OWN R ■ AGEN I% 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."V'ate tot -best of my .r wledge and that all plumbing work end Installations performed under the permit Issued for this application will be in compliance , . e . • s• of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A WINSLOW I LICENSE# 12298 SIGNATURE MPD JPO CORPORATIONa# 3281 PARTNERSHIP©# LLC D# I COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CCS ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL EMAIL ACCOUNTSPAYABLE 0EFWIN'j!„ 1W II 1 • ACCEPTED /' _ 7 20)2 • BY: h/a77All0 BUILDING DEPT -- - BY_ / / 1 .. . 4 • 3 • • • • it C*' I .. - r T; e - • - t - - C V b F • Ci 3 .- I - Sa,LON MaIA31I NYId - 11 1.111183d S 333 ❑ ❑ LW113d 3H1sY s3A213S NOI1VOIlddV SIHt C ON sok SILONNOLLO3dSNI'WWII A'INOash 3OIAJONOdMO73H S31ONNOLL73dSNIONIHWIfldHO(lON { - - - - 1 • I