HomeMy WebLinkAboutP-13-392 t
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-=uw CITY '/4-rm, ' I MA DATE) /j-/(p-/2 PERMIT# 0/3 — 29Z •
JOBSITE ADDRESS til gt�GJ/n0nd (A71
we OWNER'S NAME hr117dpe/ij I
P OWNER ADDRESS S Vimfyf/O-/�, . , I TEL S11 /9915" IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 / , EDUCATIONAL 0 i RESIDENTIAL 1-.1.---- '
PRINT
CLEARLY NEW:0 RENOVATION:❑ ` REPLACEMENT: PLANS SUBMITTED: YES 0 NOE<
BATHTUB
S 1 FLOOR-. BSM 1 2 3 J 4 J 5 J 6 7 j a i 9 I 10 11 I 12 Jr 13 J 14
CROSS CONNECTION DEVICE t
t, DEDICATED SPECIAL WASTE SYSTEM
(`V DEDICATED GAS/OIL/SAND SYSTEM �' 4
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
( DISHWASHER 1 ... 3 ,- `
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DRINKING FOUNTAIN
-6Z FOOD DISPOSERI ^
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) ' r'KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
1 s
URINAL 14s I `
WASHING MACHINE CONNECTION A
WATER HEATER ALL TYPES r
WATER PIPING -
OTHER
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1
INSURANCE COVERAGE: •
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
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 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 . 'NEONL : OW'E' 0 AGEJU
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are '. ,nd - urate to e best of m nowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In complian - / all Pe provi •r of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A WINSLOW LICENSE# 12298 SIGNATURE
MPD JP CORPORATION0# 3281 PARTNERSHIP❑# LLCQ#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CCti ADDRESS 8 REARDON CIRCLE I
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL EMAIL I ACCOUNTSPAYABLE@EFWINSLOW.CO Jt,t 6 L 6 [1 { 2 D
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