HomeMy WebLinkAboutP-12-640 - -. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY /✓f Yoti4h 1 MA DATE e6---...i/-/ PERMIT#? 2'tStV
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t N o I i JOBSITE ADDRESS /S+/'(/S`.pn u/? a) / A., OWNER'S NAME Atc
c*1 1 OWNER ADDRESS ' 62 7'Gt41/'Y1 mlf1� I TEL J* ?,74'OMe/FAX
� PE bR • OCCUPANCY TYPE- COMMERCIAL❑ EDUCATIONAL ❑i 1//9.RESID�NT-II�I
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S.–cLEARLX i NEW:0 RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO92
'� FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 T 13 14
BATHTUB
CROSS CONNECTION DEVICE
O DEDICATED SPECIAL WASTE SYSTEM
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DEDICATED GAS/OIVSAND SYSTEM ! 1Hh$I1I
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DEDICATED GRAY WATER SYSTEM 11
DEDICATED WATER RECYCLE SYSTEM 1 a
DISHWASHER
__c,7" DRINKING FOUNTAIN
'e FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR _ _ I E
KITCHEN SINK
LAVATORY 5,
ROOF DRAIN _
SHOWER STALL Ir I li -re
SERVICE I MOP SINK _
TOILET
URINAL
WASHING MACHINE CONNECTION II
WATER HEATER ALL TYPES
WATER PIPING
OTHER , –
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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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 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.
ONt ONLY: 0 ER ❑ A ❑
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 rat; • ' best of y nowiedge
and that all plumbing work and Installations performed under the permit Issued for this applicator will be In compile ' al •e ' e• ..••,..• of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE
. MP❑+ JP 1:1 CORPORATIONQ# 3281C PARTNERSHIP❑# LLC 0#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508.394-7778
FAX 508-394-8256 CELL N/A EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
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