HomeMy WebLinkAboutBLDG-15-003292 J I MASSACHUSETTS UNIFORM APPLICATION FOR A etJMII IU rttu-tat-ow lIAO ri Ivo= YYVM
ca T Y: es.0-;LI Ma DATE (A i ro i( PERMI .; i3dpb-/5=o03$9Z
JOBSPTtADDRESS: 1141 CirCu; 12 . floei4 OWNER'S NAME ORS 6A:30
GOWNER ADDRESS- TEL' FA^
TIPEOR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENIALr
PRINT
CLEARLY IE14/:❑ RENOVATION:0 REPIACEEMENT:0 PLANS SUBIvt II i ED: YES❑ NO❑
APPLIANCES? FLOOR-. Ssmt 1 1 2 3 1 4 5 5 7 1 8 9 10 11 12 13 14
BOILER 1 I
BOOSTER 1 I
CONVERSION BURNER
COOK STOVE K I 1
DIRECT VENT HEATER
DRYER
FIREPLACE I
FRYOLATOR I —
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK •
I I
MAKEUP AIR UNIT 1 j
OVE fl IIt
POOL HEATER I
ROOM/SPACE HEATER
I ROOF TOP UNITTEST
unirr HEATER
I 1
I UNVENTED ROOM HEATER I I I 1
WATERh'EAItrt I I I I
•I I I \ 11 I
INSURANCE COVERAGE
1 have a currant nabwin/insurance policy or its substantial equivalent which meets the requirements of NIGL Ch.142 YES41 NO 0
If you have checked YES please indicate the type of coverage by checking the approprials box below.
LABILITY INSURANCE POLICY 173 OTHER TYPE INDEIMIlY 0 BOND 0
OWNER'S INSURANCE WARIER: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 permitappGcadon waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWER OR AGENT
hereby army that all of the details and information I have submided(or entered)regarding this appBcetion are true and accurate to the best of ray
Knowledge and that all plumbing work and installations performed undertha pend issued for this application will be' camp ce with all Pe. inent
provision of the Massaolwsetis Stare Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASH I I tit NAME: 4+12 13''N Ft 2q. Ic r i7 LICENSE#A 2(a SIGNATURE
COMPANY WE: M R tP�� .�— (2',Ce ADDRESS: 3Y f Elle
S `
CITY: (eA ertL \le STATE CVO ZIP: 696 309 FAX:
TEL: CELL Sol 776'1?3a EMAIL'
MASTER( JOURNEYMAN❑ LP INSTALLER 0 CORPORATION 0 a PARlit .SH!)0.1 LLC 0#
sol sir
oUGI G i,I' r - •, ► e lg • 111118 MOS'I+O1UN P]6CFO1l USE ONLY FINAL INS:ma1 i0N NOTLS
Yes No
TRIS APPLICATION SERVES AS TIIE PERMIT ❑ 0
FEC: E PERMIT
FLAN REYI41Y NOTES