HomeMy WebLinkAboutP-13-097 $' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY /t}r✓Y TM.' MA DATE 097 `
_:NIS j��" �h �'�PERMIT# `P�'J' 1
JOBSITE ADDRESS I/ / et', da d- :Kyr OWNER'S NAME C/Q-QA # nn /
J1n'
P OWNER ADDRESS VU✓rnDIJ W ? i) tit- I TEL a id FAX (
,1
TYPE OR OCCUPANCY TYPE COMMERCIALit EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES❑ NO[ '
FIXTURES 1 FLOOR-• 8814 1 J 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1 1 11 if t y' 11I _I .1 i
(j CROSS CONNECTION DEVICE ^�
DEDICATED SPECIAL WASTE SYSTEM I li 1 _,_ T 1 r, it A
DEDICATED GAS/OIUSAND SYSTEM F r u I rI g . tc
1 i
DEDICATED GREASE SYSTEM
- I
`\ DEDICATED GRAY WATER SYSTEM lr ii r tin "i ' ' —r1
DEDICATED WATER RECYCLE SYSTEM _ r fir. _ Jr k ' of Y' I i , /nc L ,
DISHWASHER dr —
DRINKING FOUNTAIN „ _441 ' L1 f '
O FOOD DISPOSER r._- fG ii
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) 1 1 1 1 _
K _ TITCHEN SINK
LAVATORY f I I r I
ROOF DRAIN
- SHOWER STALL I I
SERVICE/MOP SINKI I I
TOILET 1 � -
1
URINAL 1 7 _ _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 'I
OTHER i Iil 1
I
1r rI r r _- I rr r
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO D
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND Q
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. ,
CHECK . ONLY: OW, R I/ AGENSIA
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 ac to th- •es of my k f• ledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance wi •erti .nt• o son• the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A WINSLOW LICENSE# 12298 SIGNATURE
MPI ' JPD CORPORATION O# 3281 PARTNERSHIP Q# LLCQ#
COMPANY NAME E.F.WINSLOW PLUMBING 8,HEATING Cc14 ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH . STATE MA ZIP 02664 J TEL 508.394.7778
FAX 508-394-8256 CELL I EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
•
- .,-, I
0„
r i ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
•
•
t _
•
•
j ,