HomeMy WebLinkAboutP-13-661 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ri441== CITY l c 01717-1 .h/1,01.1.60 1/1 I MA DATE V'A a PERMIT# 0"3^ 44,I
JOBSITEADDRESS s4' t0//V4/NG• e,201,4a IOWNER'S NAME[ LI)I.�L kg()E. I
P OWNER ADDRESS TEL sa 13 9f Q 2:1 41 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIALD
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ 'mop
FIXTURES 7 FLOOR-. BSM () 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB II I ,I l r 1-7
11 a I Jr
I' _ I I
CROSS CONNECTION DEVICE II.
DEDICATED SPECIAL WASTE SYSTEM n� r r , rt' _r- r Ir _ 1
0
_ir
DEDICATED GAS/OIUSAND SYSTEM o I r
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
— DEDICATED WATER RECYCLE SYSTEM iii "pi I 1
DISHWASHER
DRINKING FOUNTAIN I.
El
FLOOR/AREA DRAIN �,FOOD DISPOSER SSUR �,
INTERCEPTOR(INTERIOR) sum l�'I o INKTOILET
WASHNG MACHINE CONNECTION 111111111111111 WATER HEATER ALL
B SHOWER VASVE : » poRre:
OTHER ( If
-777 7 17 IF ¶r Fl
- INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND y 9
❑ ACCEPTED y`
BY: .
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by ap er
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT 0
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 e ne t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.;
PLUMBER'S NAME JEFFREY CARLSON LICENSE# 8932 �/ I,, ATURE
MPD JP Ell CORPORATION 0#2430 PARTNERSHIP❑# LLC a#
COMPANY NAME BATH INC D/B/A AREA PLUMBING ADDRESS 25 TURNPIKE STREET r, (J ,,, n n F 1
ii-, I
CITY WEST BRIDGEWATER STATE MA ZIP 02379 TEL 508-521-27001„ l I I
FAX CELL 508-989-3271 EMAIL l i] 'IJ 0 2013
0 4 0
IDY. ---t -----
1
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
1 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
{
PLAN REVIEW NOTES
•