HomeMy WebLinkAboutP-13-579 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
`+= I_= t CITY I k)k c7 h U ti11R.rI MA DATE ,V-5$"; I PERMIT# 05 — 5799
JOBSITE ADDRESS Jot A .k i'AI ,en7t-L_ ( OWNER'S NAME Wig.. 1(c AUCC I
P OWNER ADDRESS TEL 5D?'/$D 9.36 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
PRINT •
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES 0 NOD
FIXTURES 2 FLOOR BSM l% 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 'LI If J 11 1111 II ;I �[ ,[ If 1
CROSSDICTEDCOSPECIONAL DEVICEASTE _ _ illi
i, 'I
DEDICATED SPECIAL WASTE SYSTEM 1 1
DEDICATED GAS/011../SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM I '
DEDICATED WATER RECYCLE SYSTEM II n fi
DISHWASHER ; ,I
DRINKING FOUNTAIN
FOOD DISPOSER ,, li iI
FLOOR/AREA DRAIN
ERIO
(INTERIOR)
7 H -Ii
I 6 _LIP SINK P1111111
TOILET F �� r —F 'I 17
URINAL J i li _- ; . I,—
WASHING MACHINE CONNECTION I i II It q
WATER HEATER ALL TYPES it i h '
WATER PIPINGun SHOWER VALVE �
OTHER i 1 i --- -
II
1 d i! s 1 , I i i , I
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 9 OTHER TYPE OF INDEMNITY 0 BOND❑
OWNER'S INSURANCE WAIVER:lam 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 El 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 true 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 compliance with all Pnt prr vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ fri/
//PLUMBER'S NAME JEFFREY CARLSON LICENSE# 8932 TUR
MPD _ JP❑ CORPORATION D#2430 PARTNERSHIP❑# LLC 0# —''
COMPANY NAME BATH INC D/B/A AREA PLUMBING ADDRESS 25 TURNPIKE STREET
CITY WEST BRIDGEWATER STATE MA ZIP 02379TEL 508.521-27gr' L 5 'S " ")
FAX CELL 508-989-3271 EMAIL Itl MAR 1 1 7013
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t;UILOi. G =PT
By
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES