HomeMy WebLinkAboutBLD-23-003480 " #1 I
ONE & TWO FAMILY ONLY- BUILDING PERMIT IlitiC(LI
Town of Yarmouth Building Department :• 'oF"r .
1146 Route 28, South Yarmouth,MA 02664-4492
R E C N .�'r!� ■508-398-2231 ext. 1261 Fax 508-398-0836 t4 1'
'1 Massachusetts State Building Code,780 CMR
rDE232022Bu IdigPermitApplication To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
TTJIr=PIT
BUI:DI pipAR__-- ..-_: This Section For Official Use Only
BY _ u�-Z3-00 -
Building Permit Number: 6 � Date Applied:
11 i(- aV--
Building Official(Print Name) • Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Lill Csak Is\arct a#1Dj NU,YIYtAtia,13
.� Number Parcel N,imbef
1 1.1 a Is this an accepted street?yes 26 no . .- :?.p •-,Tibe
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required I Provided Required Provided Required Provided
1.6 Water Supply: (Ivi.G.L c.40,554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public ctt _' Private 0 Check if yes❑ Municipal p On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP
2.1 Owner'of Record:
S6SCIn Farv(\ `0'1\1 (41 , MY1i b2L1
Name(Print) City,State,ZIP
LVe +i`, f v_IstanA 6#10 TN-LIic1- 1192 usQnni h-tna 9ma.i).apt
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing BuildingELI Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg. ❑ Number of Units Other G3 Specify: re y jrX,.? i
Brief Description of ProposedWork2• t1J2 •rp Sy1Gy�i-C.ir f bnve c`� Ai Z j
V��,lM _Sw4 00 , cam— 4 ez ` ` .,- .
G� c 5--)..._ i lr�T j ,tit ( 1 t-<��` eCAiLti U (1,1 .4c ce,c.,,,c , �ri_,— s;.,.1i .
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ LAD t-i--P 1. Building Permit Fee:$ 1I(Indicate how fee is determined:
2.Electrical $ O 0 Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing __- $ noo 2. Other Fees: S__ _l s'"71 L.93 S
4.Mechanical (HVAC) $ 0 List: C 1/ I�-1-/ I a 0
5.Mechanical (Fire $ �` - tC•
Suppression) L} Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ tilkitstM ❑Paid in Full 0 Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) , l 0 , < /1 li 242-3
`—' t ` LiJ D License Number Expiration Date
Name of CSL Holder J
t List CSL Type(see below) t.
t�(; -tUrni) 1nr-c _ks t -1--
No.and Street Type j Description
) .)}LUr;,l AP\ 1'�3'73-2 (V, i Unrestricted(Buildfn€s up to 35,000 cu.ft.)
City/Town,State,ZIP R { Restricted l&2 Family Dwelling
M ' Masonry
RC Roofing Covering
WS I Window and Siding
`2()14�i 1 SF Solid Fuel Burning Appliances
'- b �o� kt I 0692{iS ��t•Cl�v� I Insulation
Telephone -- Email address D Demolition
5,2 Registered Home Improvement Contractor(HIC) _
A I --I is-U.t.A—,. S uC.._ Cum.pe,,,,S-( & 1A ! c1 Oa 2 -..tion Number
HIC Registration i
HIC�o parry N e or I�.IC Registrant Namr�
Expiration Date
„ rtY-6. ;Q,r-�- 6i,r10 t S z 1�`�- )< , �c).-N'1
No7 and Street i
1 t v�L,re9 , 11'Y(� O-2-7-Lc' ) ^I�i g�{g ( 1 '` Emailaddress
Lay/Town. State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes l No ,0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
• SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
t - -uth z k* 7
�Owner�s or Au:hb�zed,4�•en Name E�'��, 1 — �Z � I �U��j s ( ,,conic Signature) /
Date
-- NOTES: - ------ —_-- }
{ I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will nor have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.)_ - , (including garage, finished basement/attics, decks or porch)
Gross living area(sq.ft.) _ Habitable room count
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of half/baths
Type of heating system_ Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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The Commonwealth of Massachusetts
MjitrA..in Department of Industrial Accidents
-- 1 Congress Street, Suite 100
" Boston, MA 02114-2017
.% www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 41 1 r 117 tt (s L L-C- g -Cy c .-k t,!
Address: if,- _ � 2 Pa/ ��f V,
City/State/Zip: , / - 0"735-ophone #: - - b- Go L-f 1 Li
Are you an employer?Check the appropriate box:
Type of project (required):
L 2 /'Lek am a employer with S7 employees(full and/or part-time)."
7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8• Remt)delin�
3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work onproperty. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sol
proprietors with no employees. p I I. Electrical repairs or additions
t
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12. Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.: 1 -❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I4.❑Other
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box WI must also fill out the section below showing their workers'compensation policy information.
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
(Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
r`
insurance Company Name: '0- St, 01 ( N.,k )tdc -s c t ,t<.7 A
Policy#or Self-ins.Lic.#: W C'�^ t-ij�.0_t{" i Z,O�
7 2/4- Expiration Date: I 1 2'9} 1-2--3
Job Site Address: ' 981 8U a vdtk na Cd illlf 10 City/State/Zip: y;,l(flilii tt"L tint( LL1,,i -
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL G. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: L, yt2L7(.4)
Date: I 'll/ 7/22
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
•
City or Town: Permit/License#
Issuing Authority(circle one): -
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
_. Phone#:
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§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at L\ I t C1C clan ct Q rt �A-10,*An'Y1,61J 1-. m(A �%2�16
Work Address
Is to be disposed of oat the following location: 55 B C D9D0Y-0-A-C e L .
C L 359
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
{� - iy:,. lzl17 iZ2sSi ature f Applig(t)
ion Date
Permit No.
4 _
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55B Corporate Park Drive Home Improvement Contractor Bay State
Pembroke,MA 02359 Registration# 193023 ((-1—`-----------------':"-------- Bath
Phone:781-826-4141 /
Date: y Z 1—21 Jowl: Turned In On: vet✓rat O l q,7
1 el
Floor: c. J (i.e.Basement(Slab).1st FloorInd Floor) Main Water Shutoff Location: e nowt.
Desi cr's Name eit dicte I Marketing Source
Name 7G.n C -tg _ HomePhone '
�
Address I 15/4 Condo i) -l7 Work/Cell Phone-47 4 ���} 77 9 Z __
('it"Stale/i ()).\ mW4' 4 4 0 Email U _ wr• eoik ((....-
BATHTUB(custom tub must Include measurement form) SHOWER DOOR
' Corot. S Style: Len: :5 l la,•ht. L R
Size: D ain:[ I L [ I R Frame Finish: 1 1 Chrome (/f BN ( J ORB
Drain and Overflow: Chr a RN J_ORR Glass T p: Clear Rain Obscure
/ Glass Thicckness:[iJ r% I Pr[ ]Bs. (II Towel Bar&I Knob( J Dual Towel Bars
. - le:o'haf•r :1'. - S Glass BI.• [ (Pivot ( (Custom
SHOWERKustambaseirii 'firclttdemeastiretnentforlla sII(1\\Ilt( Ilt(\I\
Color:,,.01,,t)_e_ Height:31IL Length:rt W'idth:..51. I ]Crescent Rod I JCH "IORB ( IBN
Drain.I L t tR I J C Color:[ j Cm e [/)'BN j I ORB I I Straight Rod ( 1 ORB ( )BN
S110111 I2 SE.STING
.. , \%'ALL SURROUND Fold Down (Wood Color) (Hinge Finish)
s'''t Color ft Aar(4tt r,�
Type[�mo lb Acrylic Bench (Color)5.10.A.`I (RHO
He Prns e•Palen [ )4x4 [ ]ors [ ]Idxlo t 112xI2 Acrylic Comer Seat (Col,•r,
[ )Subway I IPia ACCESSORIES
m
-sm. Impressions Laser Etched Pawn .. ingk lies Shell Color sAn+1./lit/ Quantity 2_
Laser Etching Color[ (Black Othello 1 )Gray Line:( )White Other:
1
( )Irrvisu Shampoo Shelf ( I Invisu Corner Shelf [ J Imisia Accent RingCeilingCeiling Panel:[/rY ( IN Color wti 1 f G
• •
I )Fool Rest [ ]Soap Dish I >.n
Soffit Cover:( I Y (ij'N Color .3 -.
Career Trial t I V (•rfl Color. ( I dshclrt C `4.
l_y^,
Window Trim:[ ]Y ((41'1 Color. [ 1 Tower Caddy w Shave Stand
Wainscot:I ]Y ,.. rl Color. Linear Feet:
[ bar I ] [ )Bar ORB 1/r� Size,/N Si
Outside Comers: Inside Corners: Seam Cover. >98" S� t"
I'1.)\l ltl\G Il'I l'Rhr
Valve: I .j'1°ES I I NO Condo:[ ES 1.(NO
I )Diverter for Handheld 1 I Three-way I,(-Hand Held MA/rn•( 1
Brand: -_- ,L Finish I ]Chrome [dikreq 1 (ORB I I Rain Shower I lead (.I RN I I Cl-romc i 1ORD
ADDITIONAL.EI'E\IS I WORK/CUSTOMER INSTRUCTIONS
,Sera 1,.,,11 Se( FlyluRca-?1r.n t&h femc
NO ADDITIONAL WORK TO BE PERFORMED OTHER THAN THE WORK STATED ABOVE
Manna of lights mamas and outlet saddle.all bath.ran.all is put cusuallr preference and we heed your help to void t:m(1sta n.Please place marks en walls aherc ytal amid like
your tight:mirrors and outletsiswitches prior to the arrival vi sue nstillers' Customer's Initials
If paying by credit card or finance company.Custulmr authritrs the company to charge the customer's account immediately for the deposit las descnitd below)and upon
installation for the remaining balance(as described bolo.),plus any additional amounts.as described heroin.or for additional products or taro ices as agreed
(Financing Account TBD upon approval).
Moan Approval: Finance Plan Number:
TERMS AND CONDITIONS
DATE Or TAANSACDON: 9 L 1 -Z.t
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A.our IAYIaitora KAM say vtn VW).MI.CUIVIaAe'1Op sal I...AND AVYNi[NIIAm I-',TIUM,Nn tVMFn by Ylal wilt W.0 .'tN.m whits V.I..YUHNt.DAYS tawlnaaus
tin tilt at uY rrarianri.01 YouiCAA'(1ctlrnm Mlrnt.ANnsl1'YTN INTint51 Aa151W:ear lY nHl rasNsxnitlws null Yl`47.,W1U In t'ANttl 1Mi 0YAr+>ACRntt MAm-Kit
Ottlsn*AaY,X1DAALOATtmttrnot r11I CANtn:lutN,H canto.(w Or1Oa flint 1.1-no ass Sian Lull 50.ttatMw AR 1AYa Iw.RA1nwst.Walll..ORa1ND AM 01All rD
(Art,1.nAYsrATaaatutNl>ruranuNMlrx+N,ln !�—t� .:aL1. 3 3
ils ptvrdN dale h a.c.Omue Ara nA a auanwaN run dnc a.Ie IVY. a
Estimated Stan/End Data L,1MId Sun I. ran e l i.l I. „
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info PI it NAM 4(.YIla1F.l IS SU101-il IV APPMVI'A1 IA HAI it A II If ell; ,♦I,1 Al loll 14,N II%All IPIAtitI .
INIA At.Yla Vail l S St Ilt.s i(U lit Artaalllln,l Ikon,OA,1.,Yr,llt,o.,si I!lob ill t,Y I fit SA(.ICSIDt or TIDS►mat
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Home Improvement Agreement: Detail Invoice I Specifications—Phase 2
e 71on , 5u5c.n I 1
Customer's Last Name.First Name Job No.
,.d 'Veld
.,e ELECTRICAL
Iti
❑By Homeowner By BayState 0 Installation/Labor Only ❑By Homeowner 0 By BayState ■In allation/Labor Only
❑Exisiting Rough-In ❑Update to GFCI I Wh' 0 Ivory ■ Brown
JBjRough-In For New Fixtures(See Below) ❑ New Dedicated Circ,' )with GFCI : eaker
$�New Shut-off Valves 0 New Diverter 0 15 Amp ❑20 Am.
a--New Supply Lines 0 New Venting ❑ Bath Fan
Removal and Reinstallation of Existing: Make Model Color
-efSirt(Skla44Y 0 With Integral Light Fixture
❑Toilet 0 Other ❑Lighting
FLOORING
❑By Homeowner DaBy BayState 0 Installation/Labor Only 0 By Homeowner 16By BayState 0 Installation/Labor Only
• —7 I Sy.Ft. 007- Type ''r).Y6srin \li(1' \ " lockIC, Y
Sq.Ft. � ' wct\IS 'i-1n��'ty�r! l Color Style ►'o( RfAVP. 12CPb541
Color/Style I VL bM (,N\V )1 1 It W Remove Existing Threshold cryeerColon
C 4 �6 D(New Sub Floor/Underlayment KNew Baseboard&Trim
Finish 0 Grout Color AA
Other ❑ Layout ❑Square reStaggered 0 Diamond
FIXTURES OTHER FIXTURES&CABINETRY
❑By Homeowner Q}By BayState ❑Installation/Labor
Only 0 By Homeowner E By BayState 0 Installation/Labor Only
0 Pedestal Sink !S Separate� Sink Top Thickness Y/'� ❑Towel Bars 0 TP Holder 0 Towel Ring
Make_OIY4r Size `4 iZ2 Color MyS4-190L-
Bowl Style ❑Light Bar 0 Sconces 0 J-Arms 0 Globes
1k PeA loc\ No.of Bowls 1
�'+yShMake Model Finish
Color
? L Finish e- Gloss 0 Matte
Edge Style F/t,-1- ❑ Medicine Cabinet ❑Lights
Make Model Finish
Finished Edges al--"Left Front 2Right
Vanity Cabinet 0 Std rgPrernium ��
Side Splashes 0 Left Side 0 Right Side Make(r4' Model Aver,/ Finish
XLavatory Faucet 1.
/ Wood vfc Stain eGloss ❑Matte❑Glaze
Maket)21 t Model ' ' �� Finish G!
Faucet Spread 0A-
/gle Hole 2 4' Std. 0 8"Contoured Door Front Style
s/Pulls ey BN 0 CH 0 ORB
❑Toilet Color /
Drawer Front Style
Make Model ,12i LeftHand Drawers 0 Right Hand Drawers
CI Elongated Bowl 0 Round Bowl 0 Std.Ht. ❑C.Ht ❑Filler Style ❑ Left Side 0 Right Side
Rough-In 0 10" 0 12" 0 14" S/$ 21 3%
Other Vanity Specs
❑Matching Soft Close Length Depth Height
Other Specifications ---___
OTHE, 1NORK TO BE PERIFORNfEDP.'
rrt CLEAN-UP AND HAUL AWAY ALL JOB RELATED DEBRIS
ACCEPTANCE AND AUTHORIZATION THAT THE ABOVE REPRESENTS THE PHASE 2 BATH SYSTEM DESIGNED FOR YOU:
X DATE
BayState Bath 55B Corporate Park Drive Pembroke,MA 02359 Tel (508)658-0665 Fax (7811826-2333
DISTRIBUTION: White—BayState Bath Copy Yellow—Customer Copy Pink—Bay State Luxury Bath HIC 193023
Oetall Mvoics Plume 2 06/2020
.+Attlr4i-.`w t.'a.aa+PAl.s.tci!deep+,7ri+011eillR~Pieis.,--r
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Home Improvement Agreement: Detail Invoice I Specifications—Phase 2
6 . S)5cv
Customer's Last Name.First Name Job No
FrsI- F/oo(
PLUMBING ELECTRICAL
❑By Homeowner Cli,By BayState ❑Installationlabor Only 0 By Homeowner 0 By BayS Installation/Labor Only
❑Exisiting Rough-In 0 Update to GFCI 0 ite ❑I ry 0 Brown
1 .Rough-In For New Fixtures(See Below) 0 New Dedicated uit(s)with G CI Breaker
New Shut-off Valves ❑New Diverter 0 15 Am _ Amp
New Supply Lines 0 New Venting 0 Bath Fan
Removal and Reinstallation of Existing: Make Model Color
❑Sink/Vanity 0 With Integral Light Fixture
❑Toilet 0 Other ❑Lighting
s
PAINT FLOORING
❑By Homeowner By BayState 0 Installation/Labor Only 0 By Homeowner� 0 By BayState 0 Installation/Labor Only
e Sq.Ft b.CI. Type�Gcr /l lit 1 ►i4f (c-
Sq.Ft ��2��(n,[��lS Ce,lt►+�1j color Ce�otl OAk Style kOc� Re dt TIC �d y(
- -, y3
i Color/Style -._( C ven t ®.Remove Existing Threshold(TypelCo'or,
1` tA 1 pa New Sub Floor/y derlayment New Baseboard&Trim
Finish ��1
0 Grout Color N /¢
iOther 0 Layout 0 Square ffStaggered 0 Diamond
FIXTURES OTHER FIXTURES&CABINETRY
0 By Homeowner VhBy BayState 0 Installation/Labor Only 0 By Homeowner (SBy BayState 0 Installation/Labor Only
0 Pedestal Sink 2},Separate Sink Top Thickness SQL
0 Towel Bars 0 TP Holder ❑Towel Ring
Make OI�'� Size Color~ I/4vC
5 ❑Light Bar 0 Sconces ❑J-Arms 0 Globes
Bowl Stymie/�"V��//� No of Bowls 1
Color }E�+t"'�MYS7/RiFinish �. Gloss 0 Matte Make Model Finish
Edge Style 141-/- 0 Medicine Cabinet 0 Lights
Make Model Finish
Finished Edges ❑ Left Front 0 Right
gig-Vanity Cabinet 0 Std. t4�P remium � J'f-
Side Splashes 0 Left Side 0 Right Side {Za " Model AI,Q7‘ Finish 'ltie
0 Lavatory Faucet Make
� �� JJ� Wood gucl^ Stain G� 1-e doss ❑Maite ❑Glaze
t:ak, t Q(4` Model Finish 8 AIdoi SIJY__ ll
Faucet Spread❑ iBle Hole 0-4"Std ❑ ErContojred Door Front Style
❑Toilet Color /t/gt /Pulls jd BN 0 CH ❑ORB
Drawer Front Style /aldo7't
Make Model
❑Elongated Bowl ❑Round Bowl 0 Std.Ht. ❑C.Fit Left Hand Drawers ❑Right Hand Drawers
Rough-In 0 10" 0 12" ID 14' ❑Filler Style 0 Left Side %Right Side
0 Matching Soft Close Other Vanity Specs qZ �V 3_
I reJth Depth Heght
Other Specifications. __
OTHER'WORKTO BE PERFORMED'`
0
X CLEAN-UP AND HAUL AWAY ALL JOB RELATED DEBRIS
ACCEPTANCE AND AUTHORIZATION THAT THE ABOVE REPRESENTS THE PHASE 2 BATH SYSTEM DESIGNED FOR YOU: r
I
X DATE P
BayState Bath 55B Corporate Park Drive Pembroke,MA 02359 Tel:(508)658-0665 Fax:(781)826-2333
DISTRIBUTION: White—BayState Bath Copy Yellow—Customer Copy Pink Bay State Luxury Bath HIC 193023
Det.lt Invoice Pl..2 041020
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