HomeMy WebLinkAboutBLDP-15-000964 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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,........ CITY h )toil-A i( FaitI MA DATE 107571 PERMIT# /31/.P-/.T OCb 76'
JOBSITE ADDRESS JO Mi. SAh\ 04 J OWNER'S NAME RiclAg,/ 0401/cCTO.9
P OWNER ADDRESS TEL Kap 36It)9y FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL 9
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES 0 NO9
FIXTURES 7 _ FLOOR-+ BSM 0 2 3 4 5 6 7 8 9 10 11 12 13 14
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BATHTUB u I ..._ I
CROSS CONNECTION DEVICE (� j
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM in
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DEDICATED GREASE SYSTEM a 7 ! I I
DEDICATED GRAY WATER SYSTEM If it
DEDICATED WATER RECYCLE SYSTEM I ,gm st /1
DISHWASHER .Rosi 1111 '�
DRINKING FOUNTAIN t
DRINKING
FOODISPOSERiv. Rill_
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RCEPT09aflERIO 'G 62- u �At Ruitsiirnmagnia�� lKITCHEN-61A 4 i ) } rn a , i,
LAVAT WIN\WY
ROOF D IN ..� J '' ,�(�` � ' I ,'
SHOWER AL ' ' !�, ,
SERVICE/M P ItJi( off ,, I
TOILET pJ ;, -
URINAL o+\ ��
WASHING MACHI CONNECTION I � _ ,WATER HEATER ALLTYPESlosoilitoil _i,
WATER PIPI�1 OTHR /(/�-S/IOl+1i,L /��1/� ; as:s.s:V I�I i ._ ,I � Ir ;
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 9 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY❑ BOND❑
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.
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CHECK ONE ONLY: OWNER ❑ AGENT El
SIGNATURE OF OWNER OR AGENT
I hereby certify that altof the details and information I have submitted or entered regarding this application aret . 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`. - • ith all Pe. ovislo - the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME DYLAN CLARK LICENSE# 13632 % SI 'AT -E/
MPD JP El CORPORATIONED#3621C PARTNERSHIP 0# LLC❑# ,
COMPANY NAME BATH SYSTEMS MASS D/B/A 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 DCLARK@BATHFITTER.COM
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