HomeMy WebLinkAboutG-14-723 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFO
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my: b'AQ nc/TN MA DATE />/Oct PERMrr#
JOBSITEADDRESS- Z/ (3A ss R I trait- R r) OWNER'S NAME 6rA/002-
OWNER ADDRESS- TEL _ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDBfAL'g]
PRZT
CLEARLY NEW:0 RENOVA T IONf REPLACEMENT:1S PLANS SUBMITTED: YES 0 ND D
APPLIANCES? FLOOR-. I Bsmt 1 1 2 1 3 1 4 5 6 1 7 1 8 9 10 11 12 13 I 14
BOILER 1 1 I I I I I
BOOSTER I I I I I I !
1 CONVERSION BURNER 1 I I I I I
COOK STOVE I / 1 I I I I _1
DIRECT VENT HEATER I I I I
DRYER
FIREPLACE I I I I I
FRYOLATOR
FURNACE I I I I I I
GENERATOR I I I I
1 GRILLE I I I I
INFRARED HEATER I I I I I
1 LABORATORY COCK
1 MAKEUP AIR UNIT I I I I I
I Ova)
I POOL HEATER I I I - I I L I
ROOM/SPACE HEATER I I I I I I I •
I ROOF TOP UNIT I I I I I
I TEST
UNIT HEATER
I UWENTED ROOM HEATER 1 I I I I I
WATER HEATER 1 I I I I I
I i I I Ft EG Eti/ D-
I I 1 l i 1
INSURANCE COVERAGE IAN 29 2014
I have a current liability insurance policy or its substantial equivalent which meets the requirements of shGk.C11.142 YES NO ❑
BUILDING p,s_e/Y imENT
If you have checked please indicatethe type of coverage by checking the appropriate box below- By. <'_i -S qq��, �
LIABILITY INSURANCEPOLICY EL OTHER TYPE INDEMNITY 0 BOND 0 Jrs.c°
OWNER'S MSURANCEWAVER: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 0
SIGNATURE OF OWNER OR AGENT
hereby cernfy that all of the details and information I have submtled(or entered)regarding this appficauon are true and accurate to the gest of rely
Knowledge and that all pbrnbing work and insallations performed under The permit issued for this applicafion will be in compliance with all Perfinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBEt/GASHLtNAME Ova c.74R '1_ if LICENSE ?y-6P /f G�
It51GNATURE
COMPANY NAME curt c rca ccf 1c _e ADDRESS: (VF a t-D rcz-c-Nr R3
CITY: 41 r Ar Ev/5 STATE '114— ZIP: 0.2/C -i • FAX
a re 1776 c -f 9 9' CELL 5-4..1 c EMAIL:
MASTERMASTER Tisi JOURNEYMAN 0 LP INSTALER 0 CORPORATION❑# PARTNERSHIP❑14 LL.CDnn g
•UG [GA ►t Y r • ► • E ' PDS PAGE YORINSI'JECIORWEONLY }IINAL1.NSl'CC170N NOTES
Yos No -
TRIS APPLICATION SERVES AS TI IE PERMIT 0 0
FEE: $ • PERMIT it _ —
_ FLAN REVIEW NOTES -
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