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cP MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
EP =-Ff CITY V,glzmo6/T7/ ( MA DATE s x/,'a (PERMIT# PI 2-- -- 6 2z-
JOBSITEADDRESS . '/77 /2-r t8' ' OWNER'S NAME EL/As RnGD/s
•
r OWNER ADDRESS yS TihtRA1.&jey /PD. I/-44,0/E571R My( TEL Soar-3Pr-.S7y8(FAX
0/P90
• TYPE OR OCCUPANCY TYPE• COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL '
C) PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:31 PLANS SUBMITTED: YES❑ NO❑
^" FIXTURES 1 FLOOR—. BSM 1 2 J 3 4 5 6 7 8 9 j 10 11 12 13 14
▪ BATHTUB
CROSS CONNECTION DEVICE 1[ BUM
DEDICATED SPECIAL WASTE SYSTEM
111 a
DEDICATED GAS/01LISAND SYSTEM -
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM . W
DEDICATED WATER RECYCLE SYSTEM -
DISHWASHER
DRINKING FOUNTAIN �
FOOD DISPOSER __ _ n
-
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL � -' --y, - —
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION - '
WATER HEATER ALL TYPES + ��� ��l�'�—
WATER PIPING
OTHER r
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ 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 ONE ONLY: 0 h ER ❑ -GE4 ❑
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 accurat- •the bestfly knowledge
and that all plumbing work and installations performed under the permit Issued for this ap cation will be in comer - with all -et ,ip .,' ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
MPD JP I CORPORATIONS# 3281C PARTNERSHIP❑# i LLCD#1
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL I ACCOUNTSPAYABLE@EFWINSLOW.COM
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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