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Home My WebLink AboutBLDP-19-000445 PCIefetehte r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t. axn CITY SO INH 9 A4 h'.o u-rN MA DATE IDWilla PERMIT#/ DP—/5'— /y5 JOBSITE ADDRESS 11 Uhl/N f (OA y OWNER'S NAME hi A,Q 0►A Tl Mk)fe 1 OWNER ADDRESS TEL 5-n2 4g2 U7Io FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL G PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: G PLANS SUBMITTED: YES 0 NO G FIXTURES 1 FLOOR-. BSM [Qu 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB INN it Olt MI tris is a tr MI MB la a t CROSS CONNECTION DEVICE tattMINI ttIN= trttrtlMIaa DEDICATED SPECIAL WASTE SYSTEM rrt t It MI Mr SINN tl DEDICATED GAS/OILISAND SYSTEM t it it t t It itrtrt� t trtrtrl t��;'rt,t� DEDICATED GREASE SYSTEM t NM t NM t t t t IS tr t tl tl IS IS DEDICATED GRAY WATER SYSTEM t It ill rt IS ON MMI t a DEDICATED WATER RECYCLE SYSTEM MS ra a I it SO a M MB It=[t is t DISHWASHER IMM MISS DRINKING FOUNTAIN t t It i s S fi Ill a s t,t it t FOOD DISPOSER OSIER 11t1t;t 1111tmos rpm It FLOOR/AREA DRAIN Mr a s tl a t SI rt a MI tr S M t S INTERCEPTOR INTERIOR tr MIN a tr lrtrtr/ IS NM t t jtr f: t KITCHEN SINK trtrt♦• trtrt�tt trtrt� (rtt (ctrl♦• trtrt♦•trtrt♦•t� trtrt�Mtrts trtrti trtrts LAVATORY MIN Ill5 MI t I in IS MI NMI 11111• r1r1■it fr1r1� ROOF DRAIN aaaa,aaaaaaaaaa SHOWER STALL t MN!t a slum itr fit( tl mom om mita t1 SERVICE/MOP SINK A ima is a ltl is)NE1 a n a tr a a TOILET IMINS t SIAM S r tl tt a a a a a a URINAL tit la itr trtr it n ra MN as la a;tr t WASHING MACHINE CONNECTION • t I,t it a [a SS t t t ala IS a WATER HEATER ALL TYPES 11111 a trtt 111 a t�■ 11111 WATER PIPING aiaIa a a9_aa a M l 'MIOIE NM OTHER TUB/SHOWER VALVE r�i�:� �� rMI NM ME NM[MI IME MIK trt, t, t, t< trtrt<trNMI t, aNMI NMI n af11111111 a SS so-an t'trlt t t • tom Isifln crisis a Mr a swim ism Ns INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES U NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY G OTHER TYPE OF INDEMNITY 0 BOND❑ OWNER'S INSURANCE WAIVER:1 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 1 hereby certify that all of the details and Information I have submitted or entered regarding this application aretic rat- ' " best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in • th al -erti• t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME PAUL OWEN • LICENSE# 11061 / IG •TURE • MPU JP❑ CORPORATION 0#3943 PARTNERSHIP❑# LLCQ# COMPANY NAME BATH SYSTEMS MASS DBA BATHFITTER ADDRESS 25 TURNPIKE STREET CITY WEST BRIDGEWATER STATE MA ZIP 02379 TEL 508.521.2700 FAX 508-588-4303 CELL 508-649-4586 EMAIL POWEN@BATHFITTER.COM ' 71 /. ,-7/, /19/ frfr -- 6 ,t-i S3.LON M3IA3x NV'Id 9 71 „ /j//, � O11W213d S 33d � 0 0 .UAH3d 3131 SY S3A213S NOLLY3fddY SINE ON SQA SALON NOLL03.SNI'IVNI-1 A'INO 3SII"aI33O xOd MO'Ina S3ZON NOLL03dSNI ONI>iWIYJd H01IOx