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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS K CLf4,e. /3,50—nE Ex I OWNER'S NAME UDI-U.1 ,S y n/h A LC I
P OWNER ADDRESS TEL'CO t7,9?5674 FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ NOD -.
FIXTURES 1 FLOOR-, BSM (1 ) 2 3 4 5 6 7 8 9 10 11 12 13 14
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DEDICATED SPECIAL WASTE SYSTEMnpneptiemput
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DEDICATED GAS/OI A SYSTEM
DEDICATED GREASE SYSSM 1 i I
DEDICATED GRAY WATER SYSTEM 11
DEDICATED WATER RECYCLE SYSTEM
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1 - " "� - J 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 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.
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 t . an, accurat- •the b .of in knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co -. anc- wit . I rti - o in of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME DYLAN CLARK LICENSE# 13632 ---"sir SIGNATURE
MPQ JP CORPORATION 0#3621C PARTNERSHIP❑# LLC D#
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 1
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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