HomeMy WebLinkAboutP-12-542 NI,
, , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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._.,.lfal CITY V/} r,nLlrivA // , MA DATE Gil'/C '/�PERMIT#pt2_ $ /12-
JOBSITE ADDRESS 23//lint///7 9401,x' 1 OWNER'S NAME dims/ I nil,dn)
P OWNER ADDRESS lie t/&Y' dUy-n I TEL , T840,/_1/67 !FAX , _.
KN TYPE OR OCCUPANCY TYPE; COMMERCIAL EDUCATIONAL CI . RESIDENTIAL ,
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(� CLEARLY NEW:1:1 RENOVATION:❑ REPLACEMENT: �
PLANS SUBMITTED: YES❑ NO
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FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 ' 10 11 I 12 13 14
OSS CONNECTION DEVICE -
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DEDICATED SPECIAL WASTE SYSTEM �, ,R: ,, — ( L I il V ��'
DEDICATED GAS/OILISAND SYSTEM �' , �,I I� „ 3
DEDICATED GREASE SYSTEM � �
DEDICATED GRAY WATER SYSTEM ���,�,
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DEDICATED WATER RECYCLE SYSTEM IMI r SI I f '
DISHWASHERan
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DRINKING FOUNTAIN a; �,
FOOD DISPOSER
FLOOR IAREA DRAIN _net..
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INTERCEPTOR(INTERIOR) � � �_ a�� ����
KITCHEN SINK ,
LAVATORY _.
ROOF DRAIN
SHOWER STALL IM, r al amen ,
SERVICE I MOP SINK
TOILET �.
URINAL _ r I ' �n -
'r �,r i ��
WASHING MACHINE CONNECTION I � �,�,t,�i
WATER HEATER ALL TYPES 6f • 1 Illi
WATER PIPING
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OTHER rill, _. i
Maw air i J
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❑+ OTHER TYPE OF INDEMNITY❑ BOND 0
OWNER'S INSURANCE WAIVER:tam 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 CK ONE ONLY: I NER • AG' •
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are nd pccu a to the best of m • edge
and that all plumbing work and Installations performed under the permit Issued for this appli tion will be In complian th I Peni -n •ro slo • he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A.WINSLOW i LICENSE#I 12298 SIGN;TURE -.
MPO JP 1:1 'CORPORATION01# 3281C PARTNERSHIP❑# LLC❑# '
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING 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
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY • FINAL INSPECTION NOTES
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Yes No !' - • '•••7". •C`Th7.'
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. THIS APPLICATION SERVES AS THE PERMIT El El '.
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FEE: $ PERMIT$ . ....
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PLAN REVLEW NOTES 1 .
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