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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I `;_ast ' CITY I 4rnin-cNr\ I MA DATE /0 'OT /4 PERMIT# f i -PH
I `t` JOBSITE ADDRESS 197 ElAlPIh' /7 cO tri OWNER'S NAME QAC WA/79 I
tr, . P OWNER ADDRESS I Q/ Yenfl erih ' ) I Tat mss' 775-F"(OhFAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL QO
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:93
PLANS SUBMITTED: YES 0 NO0
FIXTURES 1 - FLOOR-. BSM J 1 J 2 J 3 j
4 j
5 J 8 j 1 J 8 J 9 J 10 J 11 12 I 13 J 14
BATHTUB f .
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM . . a .
•
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER w
DRINKING FOUNTAIN t s _
FOOD DISPOSER '
I
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) a. ,
KITCHEN SINK i
_
LAVATORY
ROOF DRAIN
SHOWER STALL . • 4
SERVICE/MOP SINK _
TOILET
URINAL
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WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES L _, w
WAi
0xILS —. U „
11117-1 f" ' T'# NM
CIG i 10 201 �, _
INSURANCE COVERAGE:
I ha - -1.' v`'abfA• onceN oli y or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO 0
IFYO 01" •ter' S,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY ElOTHER TYPE OF INDEMNITY 0 BOND 0
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.
CHECORTMY: 0 ' 0 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 urate to e best of m edge
and that all plumbing work and installations performed under the permit Issued for this application will be In compliance / all Pe : t provisi.r .I the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I STEPHEN A WINSLOW LICENSE# 12298 SIGNATURE
MP JP El • CORPORATION 0# 3281 PARTNERSHIP❑# LLC❑#I I
COMPANY NAME E.F.WINSLOW PLUMBING 8 HEATING CCaJ ADDRESS 8 REARDON CIRCLE I
CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 1508-394.7778 -
FAX 508-394-8256 CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM I
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