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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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=GI—W ' CITY /l /h17 u-1-ti ( MA DATE / J�— PERMIT# Pi./ash
JOBSITE ADDRESS 3 A/ P towq,e/i SV fi->`1 OWNER'S NAME Ton Z/N CK f
P OWNER ADDRESS I TEL (0/7cf77O49f tFAX _I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ NOD
FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICEF-P _ _ i
DEDICATED SPECIAL WASTE SYSTEM , __aJ,, � , kl,
DEDICATED GAS/OIL/SAND SYSTEM 1 J J.
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 3.
DEDICATED WATER RECYCLE SYSTEM , f 1 .. 1,,,2-7.1, r
DISHWASHERIy � ,1 _
DRINKING FOUNTAIN . T, 6 V L.
FOOD DISPOSER -
FLOOR/AREA DRAIN Ir + i a _
INTERCEPTOR(INTERIOR)
KITCHEN SINK . t 1
LAVATORY tL 1 4 1
ROOF DRAIN C
SHOWER STALL , 11. - .A .S.-
SERVICE/MOP SINK _
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TOILET � „ I I - � t- i r l- -
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URINAL , 1. .. r (I- I j„ _� I
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES '1- r f I t_ 1F.,u g F
WATER PIPING U O -_�. ., y- ., ,�
OTHER TUB/SHOWER VALVE .L S. $1 j( , „ ' _� . `
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INSURANCE COVERAGE: til )
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I have a current Jiability insurance policy or its substantial equivalent which meets the requirements of MGL 1 E
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IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW OCT 2 4 2O1
LIABILIrii TY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 1:3 BOND 0
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OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required pha t
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 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 Pertine rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Jeffrey Carlson LICENSE# 8932 SIGNATURE
MP El JP CORPORATION❑# 2430 PARTNERSHIP❑# ILLC 0#
COMPANY NAME Bath Inc dba Area Plumbing I ADDRESS 25 Turnpike Street
CITY West Bridgewater I STATE MA ( ZIP 02379 I TEL 508-521-2700 I
FAX 508-588-4303 I CELL 508-989-3271 .!EMAIL jcarlson@bathfitterl.comI
ROUGH PLUMBING INSPECTION NOTES - ; _ _- BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
f Yes No
THIS APPLICATION SERVES AS THE PERMIT D 0
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FEE: $ PERMIT#
PLAN REVIEW NOTES