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HomeMy WebLinkAboutP-14-413 Q(4/ 0POoPr, �S • • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK vr, =14 CITY ., e- .ill_ ti... 1-/... .W.- 57)r__-_,-i MA DATE PERMIT# p//- V/.9 • JOBSITE ADDRESS 149- (27g, pL/ P &WNER''S NAME iJ,[„ ,-) P OWNER ADDRESS LS , ! ..._- �- __..... .. ........1 TEL i•. q • 76 FAX -. t TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL IM PRINT CLEARLY NEW:© RENOVATION:I(j[ REPLACEMENT:© PLANS SUBMITTED: YES 0 NO®+ FIXTURES 1 FLOOR–. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ^ I I,__ 't.... CROSS CONNECTION DEVICEDEDICATED GAS/OIL/SAND SYSTEM DEDICATED SPECIAL WASTE SYSTEM � , , ,. .„ .... DEDICATED GREASE SYSTEM DISHWASHER i FLOOR/AREA DRAIN 1�' INTERCEPTOR(INTERIOR) r"' 1 I� KITCHEN SINK 11.. LAVATORY r r — ROOF DRAIN ( _ SHOWER STALL SERVICE/MOP SINK • '-' ._ . I( , r I , TOILET r f 1 r I ri I URINAL I "'_I i ( - . WASHING MACHINE CONNECTION it 1--, I, ` WATER HEATER ALL TYPES WATER PIPING i --- I 1 = — I E__ OTHER L _ - _ I I- -- 1 — — - I I policy INSURANCE COVERAGE:requirements 1 42. YES[� .N0. . 11.11 I have a current liabilityinsurance olic or its substantial equivalent which meets the re ilij IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY El OTHER TYPE OFINDEMNITY Q BOND© OV• i_ -/3 By CTG 1g 715-0 lei OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the i9surance coverage required y hapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK .' I • : OWN • 0 AGEN N1 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru= =•• accu to to e best of my kny-dge and that all plumbing work and installations performed under the permit issued for this application will be In compliance F's nent provision of - Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW .1 LICENSE# 12298 SIGNATURE MPO JP0 CORPORATION 0# 3281C PARTNERSHIP®# •,___._ LLCD#L J COMPANY NAME E.F.Winslow Plumbing&Heating Co.,Inssac. ADDRESS 18 REARDON CIRCLE CITY]SOUTH YARMOUTH j STATE MA ZIP 02664 . TEL 508-394-7778 FAX 508-394.8256 j CELL IN/A ..9 EMAIL accounts•a able@efwinslow.com C/` •988- dpi. ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY ,��bJt fr b � beFINAL INSPECTION NOTES Yes No • THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# PLAN REVIEW NOTES -