HomeMy WebLinkAboutP-13-168 M
• r- • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
`;�, :A CITY tiQQmnl)Il ( M1A DATE q/13J7Oi-IPERMIT# 119- /�-1
N, \ JOBSITE ADDRESS 6 0,) p m a EtOWNER'S NAME kI In Ea J I
P \ OWNER ADDRESS Stiff I TEL FAX
STYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL '
PRINT �-,/
,CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Lt PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I�I 'I
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BCROSS ATHTUB
ED SPECIAL WAS CE r fi
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM r
DEDICATED GREASE SYSTEM I 1k. Ii a SIW1
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DEDICATED GRAYWATERRECYLE SYSTEM 1 I- �l�� 71111�1f 1
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DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAINNFOOD DISPOSER ECTION DEVI
11111
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INTERR/AREA DRAIN CEPTOR OR(INTERIOR) .. 1*I*S*1*1fl1S1m1SIJ*RiS1
KITCHEN SINK
LAVATORY III 0111141
ROOF DRAIN lippOi",7
SHOWER STALL 1 S, I I in 7
SERVICE I MOP SINK -7.11111
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1 I tl 1 1 III -1=11111111 _I
TOILET ' 1 PM 1111111111.111.[ r .11.Ili all 1111111,
URINAL 1 I NAM I
WASHING MACHINE CONNECTION _L I I _I I I 1 I
WATER HEATER ALL TYPES
WATER PIPING
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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 Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 2 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CH r E ONL : OWN:• ❑ , ENT In
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and Information I have submitted or entered regarding this application are -an$ac• rate t•the•est of y nowledge
and that all plumbing work and installations performed under the permit issued for this application will be In complia •- all P• 'n- •••vis• of the •
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER'S NAME STEPHEN A WINSLOW LICENSE# 12298 SIGNATURE
MPQ 'JP❑ . CORPORATION Q# 3281 PARTNERSHIP❑# LLC D#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CCd ADDRESS 8 REARDON CIRCLE 1
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: S _ PERMIT#
PLAN REVIEW NOTES
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