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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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a ef- CITY 50 In) ,4 M)Y10U l/1 I MA DTE ntirl PERMIT# ," 6cir
JOBSITE ADDRESS 1/5 itmiAm 0. Pons jeh I OWNER'S NAME 4o,4-y8 Erg 0 cA0A0A, ,
P OWNER ADDRESS TEL561 'JA'A.6;r FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0 .
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:Ei PLANS SUBMITTED: YES 0 NOO
FIXTURES 1 FLOOR-, BSM O 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I I 1 1 11 I r r I r .I lr dr r
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM i f j i — 11E
DEDICATED GAS/OIUSAND SYSTEM WWd i
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM ,
DISHWASHER l
DRINKING FOUNTAIN �M
FOOD DISPOSER 1hillEl
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INTERCEPTOR(INTERIOR) , , 4
KITCHEN SINK
LAVATORY
11 I IS RA-
ROOF DRAIN
SHOWER STALL RlhIiIR1PU1III c
SERVICE/MOP SINK
TOILET
WASHING MACHINE CONNECTION III � IN
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irrc - linI - 1 I I i I I 1r
• H {TUB/SHOWERVALVE ,, I .•••Ri ,M.i1
r.,14 nam1 AMMONS
Man lam' m
F—
ey __ la______ INSURANCE COVERAGE:
I .1. . curren la•I 1 y insura • policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES a NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑. 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 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicatio a - .ue and accurate to the best of my knowledge
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and that all plumbing work and installations performed under the permit Issued for this application will be in • ce with al -:mine. .rovi,- of e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME Dylan Clark I LICENSE# 13632 SIG .T •E
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MP El JP '"''- CORPORATION®#36d7 a PARTNERSHIP❑# LLC Ort
COMPANY NAME Bath Systems Massachusetts` ADDRESS 25 Turnpike Street
CITY West Bridgewater STATE MA ZIP 02379 TEL 508-521-2700
FAX 508-588-4303 I CELL 508-326-4171 I EMAIL ddark@bathfitter.com
ROUGH PLUMBING INSPECTION BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
$(D f} ,Z<o Oft ea- Withy Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
• FEE: $ PERMIT#
PLAN REVIEW NOTES