HomeMy WebLinkAboutP-12-329 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=.x:1:1- t CITY YAtf7n'771 I MA DATE( /21nl// PERMIT — 32�
.' JOBSITE ADDRESS 71/ /en 'ZE log OWNER'S NAME kci/N Y/OG$-r 1
OWNER ADDRESS sflm5 VAR nwtrvMPa 4 TEL $jf-•36,Z-J/f4 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENTS PLANS SUBMITTED: YES❑ NO❑
•• FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB CROSS CONNECTION DEVICE M aan aSe=MII l J ION r"�sonslWI. ME
DEDICATED SPECIAL WASTE SYSTEM a MI1.111,111,1111111111nlihIIIIt1 t.flL'�I'',IYtsir—
DEDICATED GAS/OIUSAND SYSTEM � full ____ ISI
DEDICATED GRAY WATER SYSTEM. )IIS ,DEDICATED GREASE SYSTEM I ' I I II11 M Alli m-
DEDICATED DISHWASHER ATERRECYCLESYSTEM MN MN Ili RN IT�'^�'IN MI�
DRINKING FOUNTAIN
FOOD DISPOSER SIM i1�'�;S,SS,S, ,S MOe�M,WMN
FLOOR IINTERCEPAREA(INTE M macro sag ass�
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KITCHEN SINK �i � �� ,
L VATO SINK(INTERIOR) �;.Ma MIAMI
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ROOF DRAIN
SHOWER STALL INNr �� `,�r!
SERVICE IMOP SINK � ff��ll
TOILET t
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WATERWASHIGMHEAACRNECONLL NECTION ■ �_I, 5 5 ;
WATER PIPING OTHER
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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 0 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 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CKONt'O : 1W R ❑ AGGN
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application t accurate o t > b-st of rr, n. ,edge
• and that all plumbing work and Installations performed under the permit Issued for this application will be In co Ila e with all "a : e' . . -'n o e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Stephen A.Winslow LICENSE# 12298 SIGNATURE
MPEI JP❑ CORPORATION 0# 3281C PARTNERSHIP❑# LLC 04
COMPANY NAME E.F.Winslow Plumbin &Heating Co.,Inc. 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 INSPECTIONNOTES
1
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ,
FEE $ PERMIT#
PLAN REVIEW NOTES - -
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