HomeMy WebLinkAboutBLDG-19-001371 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK*Fv
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CBADDRES&a Green /.nn„t 4 rc OWNERS NAME 'T•0//id rs r(-eft l.'tr✓ki
G OWNERADDRESSf wee.,hoe)i/ Cr-cid' TEL•77x/999Zt93FAX:
TYPE°R OCCUPANCY TYPE commit EDUCATIONAL 0 RESIDENTI
PRINT
CLEARLY NE) RENOVATION:0 REPLACEMENT:0 FLANS SUBMITTED: YES 0 NO431
APPLIANCES? FLOOR-. Bacot 1 2 3 4 6 6 7 8 9 10 11 12 13 14
BOLER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR '
FURNACE
GENERATOR
.. GRILLE
to INFRARE)HEATER ,
MAKEUP AIR LABORATORYCOCKR E C I
OVEN L E
4 gr
POOLHEATER I
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tC ROOMI SPACEHEATER 'jr iJ is
'1 ROOF TOP UNIT
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UNIT HEATER 3UILDINC i r
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LL UNVENTED ROOM HEATER - " — �=1
WATER HEATER
Am.' P/reit ACC
INSURANCE COVERAGE
I have a anent'lability insurance policy or its substantial equivalentwhich meets the requirements of MGL.Ch.142 YES 0 ND
Ifyou have checked ,please Indicate the type of coverage by chedthy the appropriate box below.
LIABIUTY INSURANCE POUCY 0 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVEtt I an aware that the licensee pees not have the Insurance coverage required by Chapter 342 of the
Massachusetts General Laws, that my signature on this permf application this requirement.
�` �` CHECK ONE ONLY: OWNER2AGENT 0 •
SIGNATURE OF OWNER OR AGENT
herebycertfy that all of the details and Marmatlon I have submitted(or entered)regarding gds application em We and actuate to the best of my
Knowledge end hatan platting work and installations performed under to permit lawn fortis application we be h compgatce withal Patient
provision tithe Maesadaeetts StatePkrmbtg Code and Chapter 142 of the General Lasa.
PLUMBERIGASFITTERNAME:p.QL/ll Mr {n-'jki UCB4SEI{I/r 700/1 SIGNATU a
COMPANY NAME _____---_— ADDRESS: Z- /Fr c e A /.en A C re/P
CITY• yorm�isbhrr STATE/`i/n ZIP: o' -c7S FAX:
Ta77Y99Y3f9 3 Gt3L: EMAIL: tied.19 xi /c%.o/skid k i &yo/i eD, cc
MASTE32, JOURNEYMAL� LP INSTALLER 0 CORPORATION❑# PARTNERSHIP 0# LW❑S
sMtn L ADD°ss: ,�,,e/,rhf/ot.zf ericen . rte
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01/61-
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