HomeMy WebLinkAboutP-14-163 M
MASSACHUSETTS� UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ir a-77=2
t-r CITY % nncrz 4 h I MA DATE (j ifraj PERMIT# Ply- /6:
JOBSITE ADDRESS 120 -7-1---0179/9/ Jit/VI I OWNER'S NAMEI (1#inpv-n ZC I
•
P OWNER ADDRESS I )6 -innecJSL/—zich4t'" ITEL
! rfir,{3�IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ ! EDUCATIONAL 0 RESIDENTIAL p'
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:Eg--7- PLANS SUBMITTED: YES 0 NODFIXTURES T FLOOR BSM 1 j 2 1 3 i 4 I 5 j 6 J 7 1 8 j 9 J 10 j 11 j 12 I 13 J 14
BATHTUB . _ .
NICROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
0% DEDICATED GREASE SYSTEM
IN- DEDICATED GRAY WATER SYSTEM �.
DEDICATED WATER RECYCLE SYSTEM
tvb DISHWASHER -
DRINKING FOUNTAIN ' e
/
r 4 . ,
FOOD DISPOSER
FLOOR/AREA DRAIN _
Y
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY a r
ROOF DRAIN • r r
SHOWER STALL .
SERVICE/MOP SINK .
TOILET • •
v r
URINAL
V 1
WASHING MACHINE CONNEC e• •
WAT : • • . Y•Fit D
., •. Lr G
rlyr,1 /, ' I
r at I RI-11 10 2°4
dill n 41
(f i
111 1 "fs Nee lir
•
BUILDING • 'like
INSURANCE COVERAGE:
I : c •, —rIce or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW }-
UABIUTY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havq the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application naive%this requirement.
CHE04 ONE ONLY. OWNER AGE ■ •
SIGNATURE OF OWNER OR AGENT
I hereby certify that as of the details and Information I have submitted or entered regarding this application are true and -te to th est of my k • :••e
and that all plumbing work and installations performed under the permit Issued for this application will be In compliance .o: I Pe•I nt p • .ion•
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A WINSLOW {LICENSE# 12298 SIGNATURE
MPD JPO • CORPORATION O# 3281 PARTNERSHIP❑# LLC❑#
COMPANY NAME E.F.WINSLOW PLUMBING 8 HEATING CCd ADDRESS 8 REARDON CIRCLE ' I
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 ` I
FAX 508-394-8256 1 CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
1,•in 7
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONI1Y1 FINAL INSPECTION NOTES
1;1;,. E
' Yes t.,No
-
• THIS APPLICATION SERVES AS THE PERMIT '7.!
Di
•-- '
FEE $ PERMIT 1)' • 5%."'
PLAN REVIEWNOTES j
• •
•
•
. •