HomeMy WebLinkAboutP-14-288 r/ ice
•iv" t, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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lc CITY 091.-M/t/> I MA DATE I/O -09.i g 1 PERMIT# P/9 g7
JOBSITE ADDRESS 203 /, /IID I// .g/he 4 7 I OWNER'S NAMEI,44e,r1 Gn vis/ 4mie44
P OWNERADDRESS I >h-rr cDJ '? re---/-- c I inZYl• S?S�T7 FAXr
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL ]
PRINT
FIXTURESLY Z NEW:❑FLOORRENOVATION:❑ ' REPLACEMENT:vi 5 6 T e IPLANS SUgBMITT'D:I YES❑13 e
BATHTUB r I 1 ...
1r 1 1 1
14
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM lir
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM I
DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
A FOOD DISPOSER I ,
IN FLOOR/AREA DRAINI--� r
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INTERCEE (ItiEf4mFr {I �!') IS �� r r
K0ITCHEN I ��, . �-0 L,' '.'it
LAVATORI( II k , I
1* ROOF DRAI (�f'1 9 t.JuJ •--, ' r
SHOWER ALL
SERVICE/ OPSINKI mr V V
TOILET Ry
URINAL , , i
WASHING MACHINE CONNECTION
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WATER HEATER ALL TYPES I I I F V
WATER PIPING A. V
OTHER l ., . \
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
UABIUTY INSURANCE POLICY '❑ OTHER 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.
CHEC ONE ONLY: • E• 0 AGENT ■
SIGNATURE OF OWNER OR AGENT s- /
I hereby certify that allot the details and Information I have submitted or entered regarding this application are true an• • ur=`r to the •• t of my k edge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance wi T •eminent • • - • o F he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A WINSLOW LICENSE# 12298 SIGNATURE
MPO JP EI • CORPORATIONa# 3281 PARTNERSHIP❑# LLC❑#I I
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CCS ADDRESS 8 REARDON CIRCLE I
CITY SOUTH YARMOUTH STATE MA ZIP 102664 ! TEL 508-394-7778
FAX 508-394-8256 CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No-:A.
THIS APPLICATION SERVES AS THE PERMIT 0 0 •
FEE: $ PERMIT i
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PLAN REVIEW NOTES
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