HomeMy WebLinkAboutBLDP-20-004879 II
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
i®y CITY ya/✓nn..t-In I MA DATE I�e2�/�6Co I PERMIT# 4/7�� '
JOBSIT ADDRESS v2 3 ' 44.-7 Pm-s Dr OWNER'S NAME SPa//ryr.wf, Ft,'-re. S I
P OWNER ADDRESS I J TELL,:,,3i5'412gZ. IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL (] RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED:YES D NOD
FIXTURES 1 FLOOR-. BSM 1 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 Illilill
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I ATO (INTE ■■■•■■ .■■■■■.■
INTERCEPTOR(INTERIOR _
LKITCHEN AVATORY SINK �■■■■■ _ 111®■■■1111111111
SROOF
HOWERSITALL U•■■■■ 1111111111111111111gin
SERVICE/MOP SINK 11.■■r■ ■■■■■■11 TOILET
URINAL 1111111111
.....MI.
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATERNOTHER
PIPIStq wcr Valike ■■01 ■■■■■
l� _MI
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 El
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 El AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that at of the details and information I have submitted or entered regarding this application are true 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 pile with ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' �,.1.4, 7
PLUMBER'S NAME[Paul Owen I LICENSE#[11061 SIGNATURE
MP El JP CORPORATION D#4158 PARTNERSHIP❑# LLC❑#
COMPANY NAME BathFitter Bridgewater Inc ADDRESS 25 Turnpike St
CITY W.Bridgewater STATE Ma I ZIP 02379 TEL 508-521-2700 1
FAX 508-588-4303 CELL 781-361-5072 I EMAIL Ipowen@bathfitter.com 1
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