HomeMy WebLinkAboutBLDG-15-003477 --• I nwcrun
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. . I'M CITY: jj tr 1 Uv-7'"l Mk DATE _ 1^I PE NIT#nleet)WW177
4' . E ADDRESS' e ‘(t) CA IP TS U1/4-) 4o*y(
OWNER ADDRESS: cr0 he km NAME C(4-1-1-OS .S
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TEL
FAX s
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 ' RESIDENTIAL fg ,
PRUCT
CLEARLY NEW:0 RENOVAT1ONv3 REPLACEMENT:0 . PLANS SUVA i i tU: YES G NO❑
I APPLIANCES1 FLOOR-. Bsrt 1 I 2 I 3 1 4 5 6 7 1 8 19 10 11 12 13 14
BOILER I I I I
BOOSTER I I I
CONVERSION BURNER, I I I
COOK STOVE I I
DIRECT VENT HEATER 1 I
DRYER • I I
FIREPLACE I I
FRYOLATOR I I
FURNACE I ' I
GENERATOR I I
GRILLE I I . ' r I .L '
INFRARED HEATER I I I 1
LABORATORY COCK I
I MAKEJP AIR UNIT I I ' I I LL 1
IPOOL HEATER I I 0a/2-5 I 1f
I ROOM/SPACE HEATER I I �Gy
I ROOFTOPUNI I I ! 9/0' I I
TEST I (d) I I I
UNIT HEATERI i I I
I UM:SITED ROOM HEATER I1 I I
WATER h'E Al I I , _- I 1
I I 11 II I 1 Illi 11
INSURANCE COVERAGE
I have a current.liability insurance policy or its substntial equivalent which meefle requvaments of 1ViGL Ch.142 YES S NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriam box below.
UABIIITY INSURANCE POLICY 1$' OTHERTYPE INDEMNIFY 0 BOND 0
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❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby taffy Metall of to details and irriormauon I have subr diad(or entered)regarding this appkta an are true and accurate tote best at ray
Knowledge and that all plumbing work and Ins/gallons performed under to pernui issued for this application will be in compfanr with all Pertinent
provision of to Massachuset(s Stale Plumbing Code and q Ci hap`�er 142 of the General Laws. i2/1A-2,'
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PLUMBFRIGASI-I I I Lit NAME: Ker/.) A..)J j / cartel-6S LICENSE#T5.oy 17 SIGNATURE• y
COMPANY t�AME:.Ket1 1 hrv1r ILS a'lrh4 j OL ADDRESS: 15/ c-0/-A ita."J57t
CITY- ! / 14-4JV I C STATE AA ZIP: C\1-(no 1 FAX
TEL: l-er 72 = 4d DELL' roe cc9 nor Emp2 R ; s~= t. ' I l,11 n
MASTER 0 JOURNEYMAN iii LP INSTALLER 0 CORPORATION 0 z R'" ;, : * S' .�.� 1
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NSI'L ,, g_k opr, ' 1'1LL91'AGL1108.i b�'1.L1'O1lIJ810ONLY l,INAL1.NSl'EalONN0'I•ISS• .
ou ctty�AL / AI ! _
Yos No -
-;117/71-119-f
�� T1115 APPLICATION SERVES AS TI IC PERMIT ❑ ❑
FEE; a PERMIT G
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