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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• __n= -
_N_ r CITY 'Wes+ kirmouttil I MA DATE 0 it/,QI`-I PERMIT# l2- 471
JOBSITE ADDRESS Q 77 m EEK I ANF OWNER'S NAME A i kip Pcnz1 cnln
P OWNER ADDRESS • .TELy(-FCIS-IbI46 FAX
60 TYPE OR OCCUPANCY TYPE• COMMERCIAL 0 EDUCATIONAL RESIDENTIAL[2 '
W PRINT
(� t CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:[ ' PLANS SUBMITTED: YES❑ NOE(
``.. FIXTURESFI1 FLOOR- BSM 1 - 2 3 j 4 5 J 6 7 i 8 1 9 J 10 11 12 13 . 14-
M\` CROSS CONNECTION DEVICE
J DEDICATED SPECIAL WASTE SYSTEM _ 1
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
11111
DRINKING FOUNTAINI 1 _
FOOD DISPOSER U -
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALLr -
SERVICE/MOP SINK , li ill .
s
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES + V
WATER PIPING
OTHER _
I I
INSURANCE COVERAGE: ro
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
_ ._ S \',.
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY Q 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
CH . 'NEONL'. OW ER A A
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and Information I have submitted or entered regarding this application are ,•- •nd a. to to th= .est of •wledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In complia +- f-II Perti t -24A • .1 the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. F 41
PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNA RE
MPD JP❑ • CORPORATIONO# 3281C 1PARTNERSHIP0# LLC❑#
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 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