HomeMy WebLinkAboutP-12-491 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS ;� 4`74l Ctabt2_ I OWNER'S NAMEIZI/ae d /H I i/Af l I
OWNER ADDRESS lliy/A/!ff/I4-) ' I'TEI-RA.77In•4324FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL'0 RESIDENTIAL '
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CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:51 PLANS SUBMITTED: YES 0 NOe'
IFIXTURES 1 FLOOR. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB inlill=11111.OW OIRIIIII.1. 1.11OW OW lel=IMAM OM
CROSS CONNECTION DEVICE ME MI MOMS M INN,E ME Si .,rs_—=Esi g
DEDICATED SPECIAL WASTE SYSTEM ME Mrtira,MIONII,MISlin WIfillaSW insfa
M DEDICATED GAS/OIL/SAND SYSTEM SSa aa[M,IMI,a__%11S Ma MitaOSOTfl
I\r) DEDICATED GREASE SYSTEM MI ME MI=IM MI IMIN MIR=slam Ow ma NUM
DEDICATED GRAY WATER SYSTEM NM MOi,MIGNM,NIME MOM itiAS AINi E az a MN
4 DEDICATED WATER RECYCLE SYSTEM MIOW=rNN,�; ;alOa�AM3m�1 'n�ENM
DISHWASHER NM MI In NIM M IME NC MIS WI iLiai aiiii NM
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FOOD DISPOSER =;�I, nitl�„�,�il•miiW;�,Iat,_ a,;
FLOOR/AREA DRAIN MIMINM,NMIM,I•:IMS MSMI MIN MIN NMI IMMI
INTERCEPTOR INTERIOR MIling;�:LWiaMM.;MI 1MI Sdim,Mit S,
KITCHEN SINK apmnoaIIIb a alimi ins Nis imilsoi_MKmu gni
LAVATORY nu rim,liallmlui.imillimilMINSIMINK, On
ROOF DRAIN 1.1. t111111.1110=1lMINECIIMIa1E11I=OM MI 11111(ME
SHOWER STALL MIINITAMilIaa llin1a all a aMIMI S SIR
SERVICE I MOP SINK ��'i��,0. J11.1.I1011011101.�0S11.1i���M
TOILET IMNM� M.aa —snNMa`,_MI_N
URINAL �I�����h���iSi II,01.�l��l��i�. j
WASHING MACHINE CONNECTION IM;lITISOSIMMAINIITIM INN 0.1.0111llin
WATER HEATER ALL TYPES RLiiiisu[111ER UM 111111111011•0111a,1111•1111M1,1111111,1•1111 AM MIK
WATER PIPING IIIM IIMISIII.iNIIhW 01111.1aNlill.0111,
OTHER r�,OMITI IIM Ilii 01.0.111.0miIliNtSOW=
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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 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 ❑
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 requiremen
C CK ONE ONLY: OW • ' ■ AGEN ■
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 an. : e to the b• my k • -:
and that all plumbing work and Installations performed under the permit Issued for this a'•lication will be In compliance wit' I Perone is•
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
PLUMBER'S NAME STEPHEN A.WINSLOW (LICENSE# i SIGNAT RE
MPD JP❑ ; CORPORATION O# 3281C PARTNERSHIP pit ' ILLCO#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE'
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778II
FAX 508-394-8256 CELL N/A EMAIL ACCOUNTSPAYABLE.0EFWINSLOW.COM
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