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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
c CITY yA,emn/JTh ( MA DATE 14t///p. I PERMIT#Titre 5-20
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_l JOBSITE ADDRESS 74/4 tCee 7t/9t6Wz).EP I OWNER'S NAME Citi i Sect iMeiswF1
C' 17 p OWNER ADDRESS SAt r I TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIA
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB WS' [Wal IIIM OK MN MI IMg is la. s am INK moo
CROSS CONNECTION DEVICE it IS S,IS It IIINK PI=MK MI Ill`MSS AS■=
DEDICATED SPECIAL WASTE SYSTEM Mg I♦,rEINI-S SSE tan rm,Q ow flf Ts,
DEDICATED GAS/OIL/SAND SYSTEM SUSS==SKIM SSE rill=SS Sista
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DEDICATED GREASE SYSTEM ����MUM
DEDICATED GRAY WATER SYSTEM tM' fS 5fl AIM SES SI[iini is mg
DEDDRINKCATED WATER ING DISHWASHER FUNTAINRECYCLE SYSTEM ��_ I`MIN,�I�;��IN NIL
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FOOD DISPOSER IMI,�I I�,S ISIIIIIIIIIIIM 11111111' WS Mt
FLOOR I AREA DRAIN MIM 1NM MIIIIIIIIIIS NM MI
INTERCEPTOR INTERIOR W S„W S MI Win MIS
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ROOF DRAIN NM MI MK MI MS aw 1 pi N_NM
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SERVICE/MOP SINK �r�■��i�Ill=r 'r7 L e/ nwi
TOILET ES MIIIIIIIIN MI S IMI .e�17 MIK�_
URINAL ��S NMWM E �/YI/r =own
WASHING MACHINE CONNECTION WS SOW is am Si
WATER HEATER ALL TYPES Q�;����,
WATER PIPING I�r�r� t� ' ---a
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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 O NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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
CH • !NLY: :,! R ❑ ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding is application are true a • Qocurate t ,�T9i knowledge
and that all plumbing work and Installations performed under the permit Issued for this ap•(cation will be In compllan.;k4th all 1ron of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ✓ASM
PLUMBER'S NAME STEPHEN A.WINSLOW I LICENSE# 12298 IGNATURE
MPO ! JP 01 CORPORATIONO# 3281C PARTNERSHIP❑# LLCD#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE I
CITY SOUTH YARMOUTH I STATE MA ZIP 02664 I TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM I
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ROUG P UMBING INSPECTION NOTEStlBELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
9 ? 2 ea/S 1 aim Kra— Yes o
THIS APPLICATION SERVES AS THE PERMIT ❑ s
FEE S PERMIT#?I2' 5:20
PLAN REVIEW NOTES
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