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HomeMy WebLinkAboutP-14-583 Of? (mat"G ) • 68 ' A -11 '3 " MASSACHUSETTS UNIFOR APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �301g In I ,-f CITY _.. . CAIN.. . I wfw MA DATE 2.).y./ t ii. , PERMIT# f7W 6231 0119erti... 1-, JOBSITEADDRESS a ."c,t recdone ..DR . 1.; OWNER'S NAME LACI MOS B( 1k[P\1 II /.. Aa ,--ye� P OWNER ADDRESS F _t.. _ , _I TEL Wo .9 ma FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[J EDUCATIONAL 0 RESIDENTIAL?- PRINT CLEARLY NEW:D RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES Q NOD FIXTURES? FLOOR-• BSM 1 2 3 4 5 6 Q B 9 10 11 ®® 14 BATHTUB I laltillaleirill 4, CROSS CONNECTION DEVICE ( i DEDICATED SPECIAL WASTE I � � n , DEDICATED DEDICATED GREASE SYSTEM SYSTEM TEM SYSTEM I __ Ll _ _Ilel DEDICATED GRAY WATER SYSTEM am r ( l l DEDICATED WATER RECYCLE SYSTEM _ nr DISHWASHER r ,r_ f aI�i� ina ' ' DRINKING FOUNTAIN sammtinastr ,stt_T FOOD DISPOSER Si I ._ �� FLOOR f AREA DRAIN , a r �l • INTERCEPTOR INTERIOR • I, SSIII Sflfli rr_ r MSS KITCHEN SINK � ' allf1010101.10,10.0101101int----,- ROOF DRAIN S , ,r - r. _ T TOILETRI _ aSW - — ^ URINAL � rL _�,� 1I�, HOWER STALL � � SERVICE I MOP SINK I __ - S amu s WASHING MACHINE CONNECTION / i)5ill as l ssi _ 1�Si W7i� I��r�r ♦ � ? ;� r_ i. i !. l�11 • miiimowiatifinainallielSialiallatortini IT I' I 1 - 7 '' r` INSURANCE COVERAGE: I h r'IY . ••••liry=msura l icy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D+ NO EJ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY Q BOND 0 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. CHECK i I t . OWNER AGENT Q' SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and a • -te to the best f my knowle•• and that all plumbing work and Installations performed under the permit Issued for this application will be ii compliance with aP rtinent pr vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN A.WINSLOW , LICENSE# 12298 SIGNATURE MPD JP© CORPORATION 0#L3281C,•,.,JPARTNERSHIP©#I.......; ILLC D#.111111_ 1111 COMPANY NAME E.F.Winslow Plumbing&HeatinSlanal ADDRESS 8 REARDON CIRCLE 1 CITY SOUTH YARMOUTH STATE MA a ZIP 02664 1 TEL 508-394-7778 FAX 508-394-8256 CELL CMS EMAIL I accountspayable @efwinslowcon • P;4 - 107 zi671- • tp t • • S7.LON Mautan Nrld #111013d $ :33d 0 0 LIM13d 314.1.Sb'S3A213S NOI1VOIlddV SIHJ. AOVI) oN saA saioN NOLLoaasNl zvt u3f/c� / ?so .9-7c/ -1/491 RING asa aold4O boa Mo'Ian Sa,LON NOl.Loaasm D tsanta Ia aDIIou