HomeMy WebLinkAboutP-13-564 K ' 3Z% MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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v JOBSITE ADDRESS 64.,c 8,10r £ I OWNER'S NAME /P%/J/1P/ ' "a ' '47I
,V J OWNER ADDRESS 051,4P7902.1,1 -1/—� AI TEL gby97ca FAX
TYPE OR OCCUPANCY TYPE ` COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[-
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\ ; CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:EEl" PLANS SUBMITTED: YES 0 NOEr
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
# DEDICATEDOSSOSPECIALCDEVICE SYSTEM MI MME MN
BATHTUB IME �; IMAMS,11111,011111 MN
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DEDICATED GAS/OIL/SAND SYSTEM ON N if 1111111,0111 ;1111,11111111 NS MIXIII
DEDICATED GREASE SYSTEM N 1111M N MIMI MI NMI JIM NE MO NEI
DEDICATED GRAY WATER SYSTEM NM al a IIIIM 11111,1111111jMina MN MK N IS
DEDICATED WATER RECYCLE SYSTEM N j N N... . S 11111,111111 N MIMI MIN
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WATER HEATER ALL TYPES Ma _ _ !MIN 5 MIN 5 5
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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 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 ❑ I
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 a ' ON : OWNER ■ AGENAVA
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 ate to th, best of myFredge
and that all plumbing work and Installations performed under the permit Issued for this application will •: In compliance 't' ell Perth:nt• • • i• e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME STEPHEN A WINSLOW LICENSE# 12298 SIGN?URE
• MK:!, JPO . • CORPORATION❑# 3281 PARTNERSHIP 0# LLC 0# ,
COMPANY NAME E.F.WINSLOW PLUMBING 8 HEATING CQli ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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