HomeMy WebLinkAboutBLDG-16-001111 MASSACHUSETTS UNIFORMAPPLICAI Ion run Ar=rum 1 iv r crv,.,,.•. w.. , ., .•••- .•,,,,,,
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PSR OCCUPANCY TYPE: COMMERCIAL EDUCr.Ti\IAL E RESIDENTIAL
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CLEARLY NEW;0 RENOVATION 0 REPLACEEMENT:S PLNIS SUBMITTED:ED: YES 0 NOeC-
APPLLANCES•1 FLOOR 1 Sart 1 1 1 2 1 3 1 4 5 1 6 7 8 1 9 10 1 11 12 13 1 14
I BOILER I 1-1 I 1 1 I
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1 CONVERSION SURER 1 I I I I I
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DIRECT VENT HEATER I I I I
1 DRYER I
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FRYOLATOR I
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1 GRILLE I
1 INFRARED HEATER ci. 1 I
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If you�Eiave checked aa,please indicatethe type of coverage by checking the appropdarn box below.
LIASNTY D1SLJRANCE POLJCYa'-' OTHERTYPE YPE lNDEI ITY 0 solo 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage regu>red by Chapter 142 of the
Massachusetts General Laws,and that my signage on this permitappUca7on waives this requa ement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWER OR AGENT 1
hereby tart' That of uta details and imorm-ton I have subrnitad(or entered)regarding appncavon are true and aowratatothe best of my 1
Knowedge and trial all plumbing work and installations pariormed undeu a pemul issued for this appncanon will be';, oompIanrz with BIN-bent
provision of'he Massarhusets S Plumbing Code and Chapter 142 of the General' � Laws. / i
PUNIBERIGASH i i trtHAh4E 4N o tes w y n`1JOENSE#(9414( / 514 RE
COMPANY NAW2 cSt e s Avstel b ADDRESS: dr C. • jet ' 0
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MASTER 0 JOURN L P INSTALLER 0 CORPORATION 0= +/P; NEPS-IIP❑= LLcp;
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AI' ICA 10 SE VES ASTIIEPEAMIT 0
FEE: $�-- PERMIT II — -_
$ NAII.YILIYNO'A'IY —
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