HomeMy WebLinkAboutBLDG-15-004209 MASSACHUSETTS UNIFORM APPLICATION FOR A VtKNll I I v rr_rcrvcvr, u.,u I in•-a ....,I...
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G,': k/472-m0071-1 h7AQ DATE,W6140/ArPERMIT r�/J�-Q1ya ,9
JOESITEADDRESS: .c" s- Tfl U,V/r / OWNR'SNAME: i/IN/24 Ria cry
G OWNER ADDRESS' TEL FA
TYPE OR OCCUPANCY TYPE COMI✓ErCIAL( - EDUCATIONAL ❑ RESIDENTIAL
I?RIIvT PLANS SUBMI I I til: YES 0 NO
CLEARLY NEW:0 P.ENDVATI01�❑ REPLACEMENT:0 al
I APPLIANCES? FLOOR-. BS-rnt 1 2 I 3 I 4 5 1 88 7 1 8 9 10 11 12 13 14
BOILER I I I I
BOOSTERI I I I
I CONVERSION BURNER I I I I
COOK STOVE I I I
DR ER VENT HEATERDRi I
FIREPLACE I I 1 I L
FRYOLATOR I I I
FURNACE I I I
1GENERATOR I I
1 GRILLE 1 I
INFRARED HEATER
LABORATORY COCK 1 I I
MAKEUP AIR UNIT I I
OVEN I I
POOL HEATER I '
ROOM/SPACE HEATER I I
I
ROOF TOP UNrr I I I
I TEST
UNIT HEATED, I I-
I
UNvENTED ROOM HEATER I I I I I I 1
WATER HEA IR I E 1 I I I II
- I I I I I I I I I
INSURANCE COVERAGE
I have a current IiabTTity insurance policy or its substantial equivalent which m the requirement of MGL Ch.142 YES 0 ND 0
h you have checked YES please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE PDUCY OTHERTYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER:I am aware t the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit app5carion waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have subrrirded(or entered)regarding this application are true and accurate to the best of my
Knowledge and 9iat all plumbing work and installations performed under tie pennfl issued for is applcafon will be h=prance with all Pertinent
proton of the Massarhuseis State Plumbing Code and Chapter 142 ci the General Laws.
PLUMBRIGASLI I I tKNAME: `u Zit S S£4g S LICENSE#/ai7S-- SIGNATURE
COMPANY NAME yy��ADDRESS: /3dX 370
an- yniamourh,oaar STATE /'sv- ZIP: Ca69S^ FAX:
TH:sac-tea -0'457 CELL: EMAIL:
MASTER® JOURNEYMAN 0 LP INSTALLER 0 CORPORATION❑r PARI t4ERS_4!P❑= U-O❑r_
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f l9 CS 'I'IEWY1.CLIrO1 J El1J1'OIIUSEONLY lMINALLNSL'LECI70NN07TCS
ova G S \I L "- ► -
tea �fr.°47 Yes No
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FEE: E__ --
- PERMIT 9 �.4�qy..,�.�-
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PLAN REVI41Y NOTES (J