Loading...
HomeMy WebLinkAboutG-14-281 =—` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO FEKrvt(M UAJ ri I I Inti mita. „!. , '-�c-�_'---- CITY: Lk) l/I;l2cY/Cw'"tIn MA. DATE:q-2(o-.ZG( 3 PERIJdT;i b/1 i JOBSITE ADDRESS: it r 8 /9)t U4 i vJ (CA o.Art�OWNER'S NAME: < if pall Q P4- (I Y GOWNER ADDRESS: /fs g.-7 ti e ;.•41' 511Z6"' TEL' rah -771•/S 29 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:� PLANS SUBMITTED: YES 0 NO 0 APPLIANCES1 FLOOR-. Bsmt 1 2 3 1 4 55 7 8 I 9 10 1 11 12 I 13 I 14 BOILER H f BOOSTER I CONVERSION BURNER I I I I COOK STOVE I I I I DIRECT VENT HEATER I I DRYER I FIREPLACE I I FRYOLATOR I I I I I I FURNACE I I I I GENERATOR I GRILLE _ I INFRARED HEATER I I I LABORATORY COCK I I I I I MAKEUP AIR UNIT I I I I I I I OVEN I I I I POOL HEATER • ROOM/SPACE HEATER I ROOF TOP UNIT I TEST 1 : - rl/ [ r- UNIT HEATER (J�] ) �— UNVENTED ROOM HEATER /"� WA LK HEATER I I II 'i' (SPP ?fl 7111 I it i I I iri l �U -I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0 If you have checked YES,please Indicatethe type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [tom OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that a of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in •in• • e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. U PLUMBERIGASFITTERNAME PA A n- C s Dwl r LICENSE,# ST4, ,P RE COMPANY NAME:r Jl +9n/ 'pity ) r P4 N .i A.c ADDRESS: P.0 4 e y C7 ° CITY:I...tl fir A4r4' 5ppn -r• STATE:in 0 ZIP: 4%2672 FAX ' TEL: r°(j•77c /395— CELL: Soc 23, 9Sca EMAIL MASTER©- 5URNEYMAN❑ LP INSTALLER❑ CORPORATION I#233 -) PARTNERSHIP❑# LC❑ H`!/ y ' THIS PAGE FOR INSI'rCl'ORUSE ONLY FINAL INSPECTION NOTES ROUGI[GA5 TNSI'EC'TION NOTI'S Yos No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE: $ PERMIT @ J'LAN REVIEW NOTES