HomeMy WebLinkAboutBLDG-15-003323 .--c� I MASSACHUSETTS UNIFORM APPLICATION FOR A NtKMI I I LI rt.tc-t-Lntivz tafrvz n 1 i Hill" rvvnn
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S'— 111-1 MA. DATE I2//7 //N PERMIT#ner-b-CVMA-9
JOBSITE ADDRESS- Y 5 C l„i C c LSV OWNER'S NAME ./*'e-P nit N j 5 r;+S
\\AG OWNERADDRESS: TEL FAX
PST OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL[
CLEARLY NEW:ly PENOVATIOI I�.•❑ REPLACtar4ENT:❑ PLANS SUBM H .u: YES 0 NO❑
APPLIANCES1 FLOOR 1 Bsmt 1 2 3 1 4 5 1 6 7 1 8 9 10 11 12 13 14
BOILER 1 I I
BOOSTER 1 I I
CONVERSION BURNER 1 I I
COOK STOVE I I I _1
DIRECT VENT HEATER I I
DRYER I I
FIREPLACE I I
FRYOLATOR I I I
FURNACE I I I
GENERATOR I I I
GRILLE
INFRARED HEATER I I I
LABORATORY COCK I I
MAKEUP AIR UNIT I I
OVEN! I I I
POOL HEATER 1 f •
ROOM/SPACE HEATER I IL I
ROOF TOP UNIT I I I I L I I -
TEST I I I 1 I I I I I
UNITHEATER I I I I I I I_ I I
UNVENTED ROOM HEATER I I I I I IIII I I
WATER HEATER I I I I I I I I
I 1 I RE E111/ rD
I I I I I i I 1 I I
INSURANCE COVERAGEC 1
I have a currant Iiiabt i v insurance policy or its subsaraial equivalent which meets the requirement of It GL Ch. NO 0
If you have checked Yom•please indicate the type of coverage by checkirlg the appropriate box below. B S
I ,(,t .:0T/M E NT
LIABILITY INSURANCE POLJCY LTJgeOTHER TYPE INDEMNITY 0 BOND 0 6a e
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 0
SIGNATURE OF OWNER OR AGENT l
hereby rarity that all of the details and iniormavon I have submitted(or entered)regarding this application are true and accurate to the best of my 1
Knowl=,.dge and that all plumbing work and inssllations performed under the pend issued for this applicafon v i I be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �ar A
PLUMBERIGASI II Itit NAMa&J/Y 73,-14 se•J3' UCENSE# 3064$ / GNATURE
COMPANY NAME:/an. ce#f,- P/u...>S.-S one, aAm"ADDRESS: /05 t.....-d., 41--
CITY•
1CIN• /1/4•••••-• e., rk ,Oc.� k STATE 01 c, MP-. OZ1.7< FAX
TEL: I CELL'SR-52z.-creel EMAIL:
MASTER 0 JOURNEYMAN 21P INSTALLER 0 CORPORATION 04 P rE'.S-1!P 0: Lc❑g
r, ' �'msI'AGNIfOIIINS EC1'O1tUSI ONLY }r1N�\LJNSI'EC IONNOTES
pUG G S SP re_ • 1. I, '
4---71 -----t � l1 /� Y Yes No -
dQC¢�j' �� Tills APPLICATION SERVES ASTIIEPERMIT 0 0
FEE: $ PERMIT1'
)'LAN Aifl'i W NOTES