HomeMy WebLinkAboutP-13-300 N%
fr ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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aispl� CITY ILA kBm WTI-t IMA DATE I I 110.1 MO PERMIT#." I 3-300
JOBSITE ADDRESS IN g cove gF .5 t7Al2 OWNER'S NAME Al USS 8 RUh'I
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OWNERADDRESS r TELI51g-32Z" 1231$ FAX
TYPE OR OCCUPANCY TYPE ' `COMMERCIAL❑ EDUCATIONAL 0 1 RESIDENTIAL❑
PRINT
CLEARLY ' NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES 1 FLOOR—. BSM 1 2 1 3 4 5 J 6 7 1 8 ) 9 10 I 11 I 12 13 14
BATHTUB it I
CROSS CONNECTION DEVICE I
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM IL
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM IIa
DEDICATED WATER RECYCLE SYSTEM I,
DISHWASHER I
DRINKING FOUNTAIN
FOOD DISPOSERI
FLOORIAREADRAIN ■ 4 �.
INTERCEPTOR(INTERIOR)
'KITCHEN SINK
LAVATORY
!'� ROOF DRAIN
v SHOWER STALL 1 i'
SERVICE/MOP SINK• - 4
TOILET
URINAL
WASHING MACHINE CONNECTION -
WATER HEATER ALL TYPES
Cr WATER PIPING1
NOTHER
4
IINSURANCE 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 0 OTHER TYPE OF INDEMNITY ❑ 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.
CH ONE ONLY: OWNE' • AG I .
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 and r e tot ,best of my • edge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance wit i I Pert e.I.,. Ision • the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A WINSLOW (LICENSE# 12298 SIGNATURE
MPO JP El CORPORATIONO# 3281 PARTNERSHIPC# , LLC❑#
COMPANY NAME E.F,WINSLOW PLUMBING&HEATING CChJ ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL la I _r-
FAX 508-394-8256 CELL IIntEi ,(H 41i-�;� SPAYABLE..EFWINSLOW.COM qua tlittlin li
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— ;ll ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
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Yes No
J _ -1 THIS APPLICATION SERVES AS THE PERMIT 0 0
C till FEES PERMIT$
: II PLAN REVIEW NOTES
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