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HomeMy WebLinkAboutP-13-696 I. •,-• 4, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ;'"I_h t CITY Yap-rno u_ri .- IMA DATE I PERMIT# Ply `St6 +41. JOBSITEADDRESS 1ttntT; /-e filmy jib J OWNER'S NAME Dom Thyro Gonto re? 1 POWNER ADDRESS Ianett ilmrn.yk t-t1• ,/armou'Izrodr ! TEL OW-353-Sae, JFAX - TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL LI PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO0 FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBil CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM as ma pm a sapaiiirjaMSM_ DEDICATED GAS/OIL/SAND SYSTEM mar DEDICATED GREASE SYSTEM DEDICATED -AY WATER SYSTEM ,5� DEDICATED WATER RECYCLE SYSTEM ' 'a DISHWASHER DRINKING FOUNTAIN 7 ..is r FOOD DISPOSER _ FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY I ....._ "it t.4 ROOF DRAIN o SHOWER STALL – — SERVICEIMOPSINK r TOILET • ' M URINAL d Q„ WASHING MACHINE CONNECTION ? WATER HEATER ALL TYPES (S+rxati) WATER PIPING OTHER L, __ i . ! ''`- i 'SIIIIIIIIIIIIIIIIa Nrr sa-s a r l ltn Ida INSURANCE COVERAGE: I have a current liability insurance policy 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 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. CHECK r' : • OWNER ■I AGE In 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 .-• accj-te to the •:slot my • edge and that all plumbing work and Installations performed under the permit Issued for this application will •: In compliance,, 1.II -e ine p • Islam i e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP[J JP CORPORATION O# 3281C PARTNERSHIP 0# LLC 0# COMPANY NAME EF Winslow Plumbing&Heating Co.,Inc. ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 I TEL 508 394-T& , 1, .- „ fr n ,-, 1 I FAX 508-394-8256 1 CELL N/A 1 EMAIL accountspayable©efwinslow.com IQJl L f " 'i v lS In U -n 13 umro PR GU.LMl 1a' Si9,1WT Dy ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# PLAN REVIEW NOTES