HomeMy WebLinkAboutP-13-195 ^l MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�` w4Il CITY QMho11-f I MA DATE 477//20/Z, PERMIT# Pi—,9$'
u JOBSITE ADDRESS Ks ION)Kyr f cuj 'Id 1 OWNER'S NAME 5/1/6 CO 1
P OWNER ADDRESS Sx.nnQ, I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[V PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I II Il 1 ir I I 1 I I I
CROSS CONNECTION DEVICE I
DEDICATED SPECIAL WASTE SYSTEM - 1I- 11 I 11 I
DEDICATED GAS/OIUSANDSYSTEM �, 1 I
DEDICATED GREASE SYSTEM 1
DEDICATED GRAY WATER SYSTEM I
V) DEDICATED WATER RECYCLE SYSTEM
r)O DISHWASHER �r� Y � I flflhIIiI DRINKING 11111111
FOOD DISPOSER
FLOOR IAREA NTIN
INTERCEPTOROR INTERIOR iIiiUIIUIIiI!I
I
'KITCHEN SINK
ROOF DRAIN 11"11"i
SHOWER 1
Rai iIJSERVICE glII\.
N1w.SHING MACHINE CONNECTION .".," iiiIIiiIiIIIII
I ._ ••
ALL TYPES Y Y
ia� (OTHER
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j I • I 1 l
INSURANCE COVERAGE: -1111111-1111110a-1111S-
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1.2,:ii 1 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 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.
CHE ; ' • Y: NE' ElAG• T I/
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application - :true aani cc to tot a b-st•I my • ,edge
and that all plumbing work and Installations performed under the permit Issued for this application will be in corn. ce wi II Pe - - p • -•n ••' -
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A WINSLOW LICENSE# 12298 SIGNATURE
MP JP❑ • CORPORATION0# 3281 PARTNERSHIP❑# LLC 0# ,
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CC}i ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH . STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 j CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
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ROUGH PLUMBING INSPECTION NOTES , BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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