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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ' O .H4 yr9Q.hen U r 1\ I M DATE /ItJj e I PERMIT#Tg—vi-gq2.
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JOBSITE ADDRESS /}off 1 NF / ..0A ( OWNER'S NAMEI,S/q�,SOJJ ) 22 Ott S I
OWNER ADDRESS S f l N tT I TELVD, S l 8 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NOD
FIXTURES 1 FLOOR—* BSM (i) 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSERBEI!
FLOOR/AREA DRAIN 1111111111111 11
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER TUB/SHOWER VALVE 7L
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 information I have submitted or entered regarding this application are t : - • a. ra = • - best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in • plian th al -erti• nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. GU",
PLUMBER'S NAME PAUL OWEN LICENSE# 11061 / IG ATURE
MPD JP CORPORATION#3943 PARTNERSHIP❑# LLC❑#
COMPANY NAME BATH SYSTEMS MASS DBA BATHFITTER ADDRESS 25 TURNPIKE STREET
CITY WEST BRIDGEWATER I STATE MA ZIP 02379 TEL 508-521-2700
FAX 508-588-4303 CELL 508-649-4586 EMAIL POWEN@BATHFITTER.COM
Z.R
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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FEE: $ PERMIT# yf ` /"
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PLAN REVIEW NOTES —I 0 (C / / e'