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HomeMy WebLinkAboutP-20-2202 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK YARMOUTH 10/10/2019 11 .-. CITY/TOWN MA DATE PERMIT# SOUTH SHORE DRIVE, RED JACKET BEACH INN JOBSITE ADDRESS COTTAGE 3 OWNER'S NAME OWNER ADDRESS TEL FAX_ TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO p' FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES l NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I' OTHER TYPE OF INDEMNITY ❑ 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 ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are t• e and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co:Mance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , • PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 " SIGNATURE MP[f JP❑ CORPORATION g# 3281C PARTNERSHIP❑# LLC❑# COMPANY NAME EF 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 accountspavablena.efwinslow.com WORK ORDER 513673$50.004 Y ;r rya+ F a .l o ton M'(1211 4-2 0 1 7 a���s cr>h kt r Dn ut� #r t �ea�► ct4 /EXic1'tth L. .< WiN PLt IVISIN I&HE TiNG Ott,IN A ' t�Fl„ ' . �`C� MA b2564 Phor a 5084944778 , o . proprio,„ Typenri' ett-(tc anal.„.. 0. to ;.i - t'orr :0.�.. � � Y 8 Q�od :9 D mol . vt ct�e'ab bc�u.,,"!►ui+ xors+ne.�Al 1101 0 B a t ' otstocwauct lvo oamyp o .Iwt [ i CG 0�s btta 1, t , —' 1 Op nazi t ets 12<ElPtundaag, t ,tar - M tu ►rialietattii ***aeclredt L Th31 04 0.t►q ii pi 3 atand ireva'�, ,,,,s'Can ied:the hi tifaot n a M�'9'.t w'hal 'luitlo air' :ixiquita i) 14 eF t RU ii4. `tii ° yo i., i**00'14-r.of • k1 s 4�a 5 r a r *'fit it l 1 & 1 it�j'`t1 '8 Itoti 7tii w & ita 1. iro otsktet ii 041118t s: u ve i u .40 r itati L+nor-c I eta r< a is'. d .:so'ker?campe rsat insinsurance or L l ik Below?s'th+ Yt lt: i a1 .n ltait,>rr. Ttns04ai ► I i±IUT UAL;IN.SUMN 'COMPANY W Pol1©y#OrEe1fi . ;itr#t19 A B*PZirat►on ''''''l tJi/ (i Jotx Sitio� y. Attach opy.'ni oinpt atan� if ae to anon pa8'.. h' w ng t ie p+uil ttt Tier ti o date). E t � a1i � E iLc 2,¢ mis s i ' final urolation punishableby a +g endlorona- as weft as aiv)L•. tacs in ill fotii of U-ST,3F'VWK 0 °,:o , a,i 1,,[O�t: �ti �a $ O: i.gop ctf +statexnet may be fO dedvv {7i x c.0 -_. fig c ;oi '�x t aatbs < , N p �_. e ' s 40.400.. " � 4. / : a r ..f ' jt T i,i .i iR" �i t � „:„ ,, . , s� e fi 100#OI N, ..,J17 ttf -M 6e comer Cary orYvttir d or Towm - -. -. Permit/1°n"# 1 d; t th 2::Bal ingDepttutamieitt 3 .0 tjr�'1'ei v Clerk: 4 Elc�c ical.i pe toir S PI 41114irpectar : z, -HMO