HomeMy WebLinkAboutBLDG-15-004210 2=� I MASSACHUSP I'SUNIFORM APPLICATION FORA YtKMu Wrcrcrvturi w., C I, ,W..”.l.r.l .
• G t•• Pit root/rl MA DATE A/20hr PEPJJirf r b 115- 4Ab
JDESITE ADDRESS. P6-fir M/lT! 1-0 OWNER'S NAME: .Ti'}/✓r 1£4t
ry
G OWNER ADDRESS: TEL FAX•
ISTIDP DSR OCCUPANCY YPE COMME',CIAL[1 EDUCATIONAL ❑ RESIDEN AL❑
CLEARLY IEW:0 RENOVATION:0 REPLACEMMENT:0 PLANS SUBMI I I CD: YES 0 ND.®
I APPLIANCES? FLOOR—. Ssmt 1 1 2 3 I 4 1 5 I 6 17 I B 1 9 10 11 12 I 13 14
I BOILER I I I I I I
BOOSTER I I I I I
CONVERSION BURNER I I I I
COOK STOVE I I I I
DIRECT VENT NEATER I I I
DRYER I I I I
FIREPLACE I I I I
FRYOLATOR I I I I
FURNACE I . I • I I
I GENERATOR I I I I
GRILLE I I I I
INFRARED HEATER I I ! I
I LABORA T ORY COCK I I ' I I I
MAtaiP AIR UNIT ! I I ! I
1 OVEN I I I
I POOL HEATER I 'I I
ROOM/SPACE HEATER, I I I I I
I ROOF TOP UNIT [ I I I I I I
I TEST / I I I I I I I I
I uMTHEATSR I I I
I Mara)RDOM HEATER I I I 1 I 1 I
WATER HEATER I I I I I I ' I
! - I I I I I I M I
I
INSURANCE COVERAGE
I have a current Iiabilb insurance policy or its substntial equivalent which mea the requirements of thGL Ch.142 YES 0 NO 0
If you have checked YES,please Mica's the type of coverage by checkusg the appropriaro box below.
LIABILITY INSURANCE POLICY isi. . OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WANER I am aware that the licensee does not have the insurance coverage required by Chapter142 of the
Massachusetts General Laws,and that try sigrhatttre on this permit appficalionwaives this require:amt.
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT l
hereby cirri y that ail of the details and information l have submitted(or entered)regarding this application are true and accurate tote best of my 1
Knowledge and that all plumbing work and inshallations performed under the pentul issued for this application will p ante with all Perfirtent
provision of tie Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C---
PLUMBERIGASLI I 1 at NAME LO2115 S 2421 LICENSE#lent SIGNATURE
COMPANY NAME ADDRESS:
CrrY: yi-WIOri PG/tr STATE/19.4- ZIP. 002L7r FAX:
TE: ,0&-.1,2— oe e GEL I
MASTER E. JOURNEYMAN 0 IP INSTALLER 0 CORPORATION 0 a PARTNE'S-ILP 0# tit 0 t.
.r.
211.4I'AGJ&FOR INS J CI'OIl UN ONLY .
��1NAL INSPECTION NOTES�i/60�1s Yes No —
�f� /� TIIIS APPLICATION SERVES ASTIIC PERMIT ❑ ❑
111: $_--- PERMIT a —
T Mme— 0 .
YUAN III3YIL11'NOTES L,-/- 44