HomeMy WebLinkAboutBLDG-19-002686 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK G
y_ CITY: lf�lCMv MA. DATE /D ftO PERMR0A46I4—c0gbga
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JOBSITE ADDRESS rI/evorgl a1 S`Zi/CSI hr OWNER'S NAME ,!°IAAI�/19
G OWNER ADDRESS* 5 MC TEL: lit 1085139FgX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTWL)?5,
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT PLANS SUBMITTED: YES 0 WFS
APPLIANCES) FLOOR sant 1 2 3 4 S 6 7 8 9 10 11 12 13 14
BOILER )G,
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
In INFRARED HEATER f F[ (',E Q V E D
W LABORATORY COCK
MAKEUP AIR UNIT
44 OVEN I
POOL HEATER }C T I I SLR
ROOM SPACE HEATER �----_ r
J ROOF TOP UNIT '<4..L JLr, '.1DnE r
TEST "
UNIT HEATER
t u UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES%NO ❑
If you have checked Ya please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER I am awn that the licensee&Lan the insurance coverage required by Chapter 142 of the
Massae General Laws,and that my signature on this permit application y_hnthis requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information 1 have submitted(or entered)regarding this epplcatbn are lime and accurate to the best of my
Knowledge and that all plumbing work and in staCode end ned ander the pemt asued fortis application wN be N compliance, wwitra�a�Parynert
provision of the Massachusetts State Plumbing Code Chapter 142 of the General Laws. `(l/J rrrr0 cid Cn/lLi
PWMBER/GASFITTERNAMEJMU MCDC nnLt1 UCENSEIS110 SIGNATURE
COMPANY NAME hchannCiI YHtda4I mot 5,41.1 ARES 79 cek7
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CITY. a/4T POWS/ STATE Mil
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TEL (7�r 2Y(0-3(5a- caL: SDS . y4.USG E tJ/mf/ncda7,nrU41edw1/ceC. an44
MASTER 0 JOURNEYMAN LP INSTALLER 0 CORPORATION 0 TI PARTNERSHIP 0 I LLC❑I
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