HomeMy WebLinkAboutBLDG-15-002910 �-` I MASSACHUSETTS UNIFORM AL FLIUA!!Un rums rntcm!! !v rCru-vI.,vZ 'a"-' I IIIISI.+ r..JI.1\
�= CITY: YA@vw L 595" Mk DATE: i t f r`( !I Y PERMR r/34gb-s--ar,291a
1 JOESrrEADDREss: b" ei fl V/vvi 3 OWNER'S NAME J/Wr/- tastily
,Y OWNER ADDRESS:Myth RJ. (Z-rimr,rctu' 0 TEL:6l7-it,- /25w FAX:
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' EOR OCCUPANCYTYPE COMMERCIALEl EDUCATIONAL 0 RESIDEPIiIAL❑
\ I , PRtUCT
CLEARLY. NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMI i I CU: YES❑ NO 29
APPLIANCES: FLOOR- Bsmt 1 12 3 1 4 5 5 7 1 8 9 10 11 12 13 14
I BOILER I l I
BOOSTER I I I
CONVERSION BURNER I I I
COOK STOVE I _I
DIRECT VENT HEATER
DRYER 1 I
FIR
FRYOLr,EPLACETOR
FURNACE •
GENERATOR I_1
GRILLE
INFRARED HEATER
LABORATORY COCK
I MAKEUP AIR UNIT I
OVEN I I
POOL HEATER I I •
ROOM I SPACE HEATER I
I ROOFTOP UNIT I
TEST
UNI-HEATER
U ti I I
i ED ROOM HIEATER I / I I I F
WATER h'E;TER II I I I I I I
- I r I I I I 11 I
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which mea the regi.remerts of MGL Ch.142 YES ENO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY Er✓ OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Ins,and that my signature on this permit application wthes this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby cfy Thai ai of The details and information 1 have submitted(or entered)regarding this application statrue and accurate to the best of my
Knowledge and that allplumbing work and installations performed under ate pern>d issued for this applicaiion vn11G l��rapliance'wit all Perfnent
provision of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. /rte
PLUMBERIGASHiitFtNAME: C✓K-CS St1QI LICENSE#Mfl/an.r SIGNATURE
COMPANY NAME ADDRESS: ego 3 70
Crit: !42M ou7k/9027 STATE (Vt' ZIP: 0:ae 71 . FAX
TEL sef--3L2 -o[.CZ CELL: I -
MASTER( JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0 i P„ktfs( IV E D ILep
kNOV 24 2. „ zia4..
B DEPAR MENT
8v. _.
r ;'11191'AGE FOR INHI'1CC 0111.1,9E ONLYfetr }r1NAL INS PBCI'lON NOTESOUGEEGA ,l' r g ► ► . L '
jL /f ��l`a ie/� Yas No
TIIIS APPLICATION SERVES AS TI IC PERMIT 0 Ell
FEE:
PERMIT ui�c / ��
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,PLAN RTYII;W NOTES
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