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�, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=bl� CITY Wairrirettaillella MA DATE /0;4570-/g PERMIT# 11S t9 0/
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JOBSITE ADDRESS 7 i-/JrA,/ LN IOWNER'SNAMEIpl„r/zr't, 47 rosy) I
P OWNER ADDRESS I'TELI6- 9yb(07IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL 0 RESIDENTIAL •
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q/ PLANS SUBMITTED: YES 0 NOE(
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 5.1.I;A0. in.,10.11111.1 IIIMEla,,io ,Iuff ma MI EMI
Q CROSS CONNECTION DEVICE IS MIMI SINMR SI MN 11111111S MI a M'IA'MI 5 a
l fl DEDICATED SPECIAL WASTE SYSTEM NM INNAIM',II1111111,111111la,IIIIII Imo', I I.IIIIIII 1111111,N
DEDICATED GAS/OIL/SAND SYSTEM MK,M111,11mlos',MIIBMIIIIIK,MNI♦,NS,I♦,SNS,a
il DEDICATED GREASE SYSTEM IIIIIII MI la M MI MN la 111181 M MI IMO S MI IN NS
DEDICATED GRAY WATER SYSTEM S;NE JIM;5 MIMIMI 11111111181 NE, 111111111 Inn NW MN MOM
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WATER RECYCLE SYSTEM I�;I�',S,5�,�,�_;,�_N_IIIIIII<MI,I�S N,5
v DRINKINGS FOUNTAIN II �,�SIN NMI MIN S NM MB ME NS
IIIIIII INN al=la SI amilso sit,5 Ea
FOOD DISPOSER NMI 1=o=VMIMF,M,l=i,IMMN;, , rl�amion INE
FLOOR/AREA DRAIN a IS MN NM S S MI la MI MI RI•,MII,IIi MI RM
INTERCEPTOR INTERIOR mnimilmilrimuisa, OE wi lamUFWdINTONTIMI1
'KITCHEN SINK MIR IIIIIII 111111111 JINN 5,MI S IN IIIIIff 1111111,1111111 M M a
LAVATORY 5 h011111,01111111111,I—,,_o_`_h.NIE,S s,;MIK i—
ROOF DRAIN MN S MIllninill,N NMI MIN N M,S,S,MIN•S MINI
SHOWER STALL ISMNI MES,SS,MIIIIII,MIIIIIIIIII �
,IS ;1�
SERVICE/MOP SINK MN MINI,11111111111111 NM _,MB Inn MS
TOILET It.MIN MI NMI MNN.NM 1111111.EnM.M,SMI MEI 5
URINAL NM Mil,5 S MICEINICINNIlta IMO IIIIII,INE MN MS
WASHING MACHINE CONNECTION amlimnI■Ilam,NMlaINItal■II,MIall=,woo la ma
WATER HEATER ALL TYPES fl M.N MI ME M S,S a—,5,IIIIIIII—NM N
WATER PIPING MN AM Ma NE mi,SMEOW ME,'S,M„M.0
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011.11111111111111111,111MI,N.MIR 01111111111M,M'MEI rs,Ial .MN
MIK NMMINS MSS MISS SIN EMI as--NS
al 1111111,11111a IIIIII MIR IIIIIIIIIIIIIMelni Ent NM not Ns si
IIIISIMMIll Ia Imilmilm t M—',n S— RIMILIIMI a MIR IRIu
INSURANCE COVERAGE: I r C la L I tiL
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL s' 2. YES EI NO ❑ I 1
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I NOV 0 5g
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LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0 �Uf NwOWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required •• ._' .
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK • • ONLY: I NE• ■/ AGENN
SIGNATURE OF OWNER OR AGENT �r1►
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and a 797 •the be of my kn 1�a
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with el l •_ ••-n • • in of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME STEPHEN A WINSLOW {LICENSE# 12298 SIGNATURE
MPD JP • CORPORATION O# 3281 PARTNERSHIP❑#_ LLC❑#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING C a+j ADDRESS 8 REARDON CIRCLE '
CITY SOUTH YARMOUTH STATE MEM ZIP 02664 TEL 508.394.7778 1
FAX 508-394-8256 CELL 1111.111111111 EMAIL ACCOUNTSPAYABLE•'EFWINSLOW.COM
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