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17 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
..Azilifff1 CITY yn'r(Yl n off) ( Pc f--E\ I MA DATE,1 ^..2-/y PERMIT# PH— 716
JOBSITEADDRESS /5 mrrt±15_DP 1 V•e- I OWNER'S NAME L I /-{R I r P_P-}- I
d 1• OWNER ADDRESS '_ /A m P I TEL,5ng-5%-I31//IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL D RESIDENTIAL
PRINT DV-CLEARLY NEW:Q RENOVATION:CI REPLACEMENT:D PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 I 4 5 6 7 8 9 10 11 12 13 14
BATHTUB FE 1
CROSS CONNECTION DEVICE �'I
DEDICATED SPECIAL WASTE SYSTEM 1 1 H
• DEDICATED GASIOILISAND SYSTEM f 1'
ii
DEDICATED GREASE SYSTEM r -r - I
I ill ��
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DEDICATED GRAY WATER SYSTEM ��� �� �-
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN J I j
FOOD DISPOSER A
FLOOR I AREA DRAIN
,Li F E �INTERCEPTOR(INTERIOR)
KITCHENSINK i Erna, al�
ILAVATORY i 1 I
ROOF DRAIN
SHOWER STALL 1 ii'li
SERVICE/MOP SINK
TOILET r [ f -I
URINAL II '
r
WASHING MACHINECONNECTION I�
WATER HEATER ALL TYPES alfa Man S TIMS �; —anan—},-,WAOTiE ..
' 1
ist
d A!' (1 '1n1L 'r FP.M F�
INSURANCE COVERAGE:
I h vgAiCk �Rt�i ncckAiWTpc licy 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 a 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.
CHEC ONE ONL . OWNE' II AGE V
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 an ural to the b st of my • edge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance wit II ertine provision i e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A.WINSLOW I LICENSE# 12298 \ SIGNAT RE
MPD JP❑ CORPORATIONO# 3281C PARTNERSHIP❑# LLC 0#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING Cbl ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH I STATE MA ZIP 02664 1 TEL 508-3947778
FAX 508-394-8256 CELL NIA I EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
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