HomeMy WebLinkAboutP-12-383 • -'-4
:_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
/ a = CITY /A.E'/I7CrZ�Tw I MA DATE //3v/d- IPERMIT# pit-. n3
l?' JOBSITE ADDRESS 10952 /gY//1ey it (din lam)OWNER'S NAME �DYCE /'141 t_s,q 1
P OWNER ADDRESS 3 ear AR nawo zIt) e8431 TEL ,.SZX'-383-'9 99 FAX '
14 Q TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
(Is CLEARLY NEW:ID RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-. BSM6 7 8 9 to C (fit • I
i l,a _ L, pl „ 7r
CROSS CONNECTION DEVICE 5 --- ' II- -_
BATHTUB
DEDICATED SPECIAL WASTE SYSTEM, ,,r II lay ITI—7;71
DEDICATED GAS/OIUSAND SYSTEM , -i •
DEDICATED GRAY WATER SYSTEM• „ DST
DEDICATED GREASE SYSTEM
DEDICATED WATER RECYCLE SYSTEM as _ I S,_
DISHWASHER
DRINKING FOUNTAIN 1111 L ! 1 h i
FOOD DISPOSER I i
FLOOR INTERC PATEAOR NTIN i' a la's f f
INTERCEPTOR INTERIOR)
KITCHEN SINK
LAVATORYI 1 -
ROOF DRAIN
_ lint _- y� -
SHOWER STALL I, , ll , , L I
SERVICE/MOP SINK I
TOILET
URINAL 1I 4L. - :_'I ,.
WASHING MACHINE CONNECTION I I yl I
WATER HEATER ALL TYPES
WATER PIPING i
OTHER
INSURANCE COVERAGE:
I 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.
C. ' ONE ONL • OW R ❑ A 7
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are + •- a.. ccuret> •the best o y knowledge
• and that all plumbing work and installations performed under the permit issued for this appli :tion will be In compli. th a • N n • • ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Stephen A.Winslow LICENSE# 12298 SIGNATURE
MPD JP CORPORATION Q# 3281C PARTNERSHIP❑# JLLC❑#
COMPANY NAME E.F.Winslow Plumbing&Heating Co.,Inc. I ADDRESS 8 Reardon Circle
CITY South Yarmouth 1 STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
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