HomeMy WebLinkAboutP-13-352 _ __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
irtA >r CITY Ya'z/Pin url-/ (50147.71) I MA DATE I//f 9J!7— IPERMIT# Pi a
JOBSITE ADDRESS 3/ IL 1 c/ T/Q'SE-DOWu ,CNER'S NAMEI/, ?01 F- i 41$/Gfnl
1 P OWNER ADDRESS I 5 AS1-i~i I TEL.524-16t, J'467 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Er PLANS SUBMITTED: YES❑ NODI
FIXTURES 1 FLOORS BSM 1 2 r 3 4 5 6 7 8 9 10 7 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE(ii301t1(L- I ' _I i ?
DEDICATED SPECIAL WASTE SYSTEM L
DEDICATED GAS/OIUSAND SYSTEM �1 __ �� 1 J� T
DEDICATED GREASE SYSTEMDEDICATED _
DEDICATED WATER AY WATER SYSTEM - -ir r
RECYC ESYSTEM �� - ,' -,
DISHWASHER I r I __ f
DRINKING FOUNTAIN ,fI
FOOD DISPOSER _r - !I- L
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR) I f h 41 ,
KITCHEN SINK
LAVATORY !' I[ E I it L . 4
ROOF DRAIN ! I I
SHOWER STALL r . r T Tr j C II r it -P Ti
SERVICE I MOP SINK —'( a ( r I ,f
TOILET - F
URINAL r
WASHING MACHINE CONNECTION 11
WATER HEATER ALL TYPES 1 i
OWATER THER PIPING 1_ I rr f H T
-T -r H 7
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
UABIUTY INSURANCE POUCY Q 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
CHE E 0 Y: 0 R 0 NT El
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 a a urate ,the best•f y knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In complian t I P= ' ent pro, ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1,\
PLUMBERS NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
MPQ JP❑ CORPORATION 0# 3281C PARTNERSHIP 0# LLCQ#
COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 5)0t394-77788' 'i; '9 2 I '
FAX 508-394-8256 CELL EMAIL accountspayable@efwinslow.com I IG 1�i
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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
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