HomeMy WebLinkAboutP-12-366 N. 1
j, • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
[so E-LC=
. =a!Jim 1@ CITY I Inlfss- irynxtn '( MA DATE I I f I I9 N21 PERMIT al`.--364
JOBSITE ADDRESS 17 12l ls4-cr ' Of c t I OWNER'S NAMEI KI i I I i PI U/ I ;Roils
P OWNER ADDRESS
I TELI09)9t =15543 (FAX'
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ ! RESIDENTIAL
PRINT Er
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:G]' PLANS SUBMITTED: YES❑ NO[(
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ' 'j� MMB a nom w Ijrr Razor-
nor
CROSS CONNECTION DEVICE MN MINIM a'a SILl Ski NMI pts MIS
DEDICATED SPECIAL WASTE SYSTEM NM MI=,a-IIS—ON a a h is
DEDICATED GAS/OIL/SAND SYSTEM a aiaa'a '�a IIIIII'a a nal ®a /1111B/1111BNIM S N
DEDICATED GREASE SYSTEM S aI M a -`— aid ii N`
DEDICATED GRAY WATER SYSTEM - S 1 r i'1•1111 MIMa a——�a.•1115ija_a,ma"IS
DEDICATED WATER RECYCLE SYSTEM NUE [1.1111•111.111 ajar _MN IScirISOM NM MN la
DISHWASHER ME NM nil NMI MN MN NM la WIZ=.11"1
DRINKING FOUNTAIN Irks= NM oor =CM.s on i
sm—
FOOD DISPOSER a ai �;_s i�s ;�l� _
FLOOR/AREA DRAIN NMMEI PEN NIB MNPMMI SiMIM—baa
INTERCEPTOR INTERIOR 5 S I a I s a
KITCHEN SINK a aaaIIMEN MIN MgMBaMa INN
NM
LAVATORY oniSS SS ,Soo Ism Ism',anIowaa.
ROOF DRAIN MIN a a,a a..aNMI MUM=NM
SHOWER STALL aaSarsoma1 ala uslai:srC
SERVICE/MOP SINK aSSS aaaI aaaaaS
TOILET NM NM SINN le MI NM NE MIK MI II, a
URINAL iNn,INM Aaa a S An MB ismSs
WASHING MACHINE CONNECTION M M MINI ON SI S� a
WATER HEATER ALL TYPES -- a s I�,S—a a aMIN a s
WATER PIPING f NMI
emS Sista
OTHER JIM AIM 5,,a a SM.ANN,ia_S,S.
CMN MIMEMilNMIaaM,aai:MNM
l Iada'Is u='s'maass sass SS a
NM NMI= aaaSSs�
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -
LIABILITY INSURANCE POLICY a 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 requirement
SIGNATURE OF OWNER OR AGENT C CK ONE LY: 'NINE' 1:1 AG
I hereby certify that all of the details and Information I have submitted or entered regarding this application are . ._ _ . ,. urate to - est of m Q�'edge
and that all plumbing work and Installations performed under the permit issued for this application will be in compile th all Pe I - Tt' e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.. - L I•
PLUMBER'S NAME STEPHEN A.WINSLOW 'LICENSE# 12298 S NATURE
MPD JP CORPORATIONQ03281C • (PARTNERSHIP❑# LLC❑# '
•
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING` ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-3947778
FAX 508.394-8256 CELL N/A EMAIL ACCOUNTSPAYABLE.'EFWINSLOW,COM
1 '
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
`'
Yes No
•
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
•
FEE PERMIT
PLAN REVIEW NOTES
•
•
i