HomeMy WebLinkAboutP-14---- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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L1� CITY �IE4Ir I MA DATE 7 ) PERMIT# P/7�/
JOBSITEADDRESS ff f ,ZDu7t 6. /9 OWNER'S NAME 7/SCF3 /lW2A1-P//d c I
P OWNER ADDRESS 1 TEL1.570'.Ybd 7175 FAX •
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL D
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR-, BSM rC 2 3 4 5 6 7 8 9 10 11 12 13 14
CROSS ONNECTION DEVICE X _J
DEDICATED SPECIAL WASTE SYSTEM j r
DEDICATED GAS/OIUSAND SYSTEM _mg_ _ ___ _ v II _ ' _
DEDICATED GREASE SYSTEM a (�
DEDICATED GRAY WATER SYSTEM fJ 1 i ._I.�., : i , 1 _ _ -I
DEDICATED WATER RECYCLE SYSTEM 1 i
DISNWNSHER „ 1
DRINKING FOUNTAIN ,lM,
FOOD DISPOSER _ d II
FLOOR I AREA DRAIN y
INTERCEPTOR(INTERIOR) I � it I M,i
KITCHEN SINK r-
LAVATORY
ROOF DRAIN F _,i f
SHOWER STALL I i I I-
SERVICE I MOP SINK 1 _ it I I i 1
TOILET I
URINAL . .. . ISIS 11.11 __ S
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WASHING MACHINE CONNECTION - r miiiismar WAJF�R i ins
WATER HE tt9 E\i F U ' I �I
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P,a+K 1
BUILDING D1tA4 MEAT INSURANCE COVERAGE:
I Flaw)a current 1416vincrwanco aolicy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑
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IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D 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 ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and infomlation I have submitted or entered regarding this application ara 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 fiance accurate
all Pe t isi e ,
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Dylan Clark - -- LICENSE# 13632 - SIGNA RE
MP • JP❑CORPORA ,. .
CORPORATION 36d 1 G PARTNERSHIP❑# LLC❑#
COMPANY NAME Bath Systems Massachusetts ADDRESS 25 Turnpike Street
CITY West Bridgewater STATE MA ZIP 02379 TEL 508-521-2700
FAX 508-588-4303 CELL 508-326-4171 EMAIL dclark@bathfitter.com �L
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
fl(Qll- 00L6 or 1/2/f �QIM Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT#
PLAN REVIEW NOTES