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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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l,U CITY y4Unlourg (cou•TH) 1 MA DATE /v ' J / PERMIT#elM15t*a9/ a
JOBSITE ADDRESS '/ emir /Ion ( OWNER'S NAME PATfJq 1/4-,o/Uo4-1 9 e
OWNERADDRESS y� �i.( I TELL<a.% Z FAX
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TYPE OR OCCUPANCY TYPE . COMMERCIAL D EDUCATIONAL ® RESIDENTIAL •
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'CLEARLY NEW:® RENOVATION:Eir- REPLACEMENT:® PLANS SUBMITTED: YES 0 NO®
FIXTURES 1 FLOOR-' SSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I -` _
CROSS CONNECTION DEVICE w•u►�
DEDICATED SPECIAL WASTE SYSTEM ����� �r�,� ��
• DEDICATED GAS/OIUSAND SYSTEM � ��-' "�""""�
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DEDICATED GREASE SYSTEM I II I I IalIa
DEDICATED WATER RECYCLE SYSTEMTzpin. ,s.� III�� L�A'��DEDICATED GRAY WATER SYSTEM �DISHWASHER _ am �'
DRINKING FOUNTAIN _r.ir ._,la
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nsmeness
FOOD DISPOSER
FLOOR/AREA DRAIN ( iIIMI_EL ` _ " aPINTERCEPTOR INTERIOR ,I II - an. I
KITCHEN SINK ME
LAVATORY � �i T. - , - 1�F'TFr --��r 1
ROOF DRAIN I fill II . _ -
SHOWER
STALL ; ' /'1 'r
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SERVICE SINK j _rylf`�,..
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TOILET � ,�r;���r�_�i�'I�C@LSIII�(
URINAL IIilaWl I J
WASHING MACHINE CONNECTION II l �I�
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WATER HEATER ALL TYPES - �I�r
WATER PIPING
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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 9 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURA EP ICY Q 0TH r =. OF INDEMNITY® BOND
OWNER'S'NSUNCE A ER:I a •ware that , icens"• does not have the insurance coverage required by Chapter 142 of the
Massachu s Gener s,and at my signet e r• is permit application waives this requirement.
CHECK ONE ONLY: 'WI RMI t El
IGNATURE OF OW - OR AGEN
I hereby certify that all of the details and information I have submitted or entered regarding this application art ue and a' ur. .to the•:st of my.. owledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In co :'ance ' t II Perone provis, of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME STEPHEN A.WINSLOW 'LICENSE# 12298 r �. qpr• R
MP El JPO CORPORATION 0+ # 3281C PARTNERSHIP®# LLC®#m.
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING Cfi(ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 ( TEL 508-394-7778 I '
FAX 1508-394-8256 (CELL N/A EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
/,3120027 La
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