HomeMy WebLinkAboutBLDG-15-003274 . _-. MASSACHUSETTS UNIFORM APPLICATION FOR A NtKMI l I u rttcruRWz t j O ri I I uvu vvvrnn
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jr CIT'; ( is r Lvr 0 01-1, IMA DATE f?-" /O —ft( PERMIT �j ,
11/ JOESr E ADDRESS• /7 Early IC.Oerl rhyOWNER'S NAME Karr y
D G OWNER ADDRESS: 1 TEL ,moi- 3b?--71/ 7
TYPE OR OCCUPANCYTYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL el.
PR1TT
CLEARLY NEW] RENOVATION:❑ REPLACEMENT:0 PLANS SUBMI 1 I tU: YES 0 NO❑
APPLLANCES2 FLOOR- I Bsn 11 2 3 4 5 6 7 I 8 I 9 1D 11 12 J 13 14
BOILED. I I I
BOOSTER I I I I
CONVERSION BURNER I I I I
COOK STOVE I I I
DIRECT VENT HEATER _agog
DRYER /€'1
FIREPLACE e G�y�y I s I i
F RYOLATO- n�1/�`r ;l r sil
s I I
FURNACE t I I I I
GENERATOR , �
GRILLE
INFRARED HEA a' j\LL''7� r-----
I. I I I
LABORATORY se CK....:. -
MAI4 UP AIR UN 1I
OVEN I
POOL HEATER I
ROOM/SPACE HEATED, I I
I ROOF TOP UNIT I L (I
TEST
UNIT HEATER I I
UNIT ROOM HEATER I I I
WATER HEATv I I I I '
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I I I I I I l I I
INSURANCE COVERAGE
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES.[] NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriM box below.
UABILRY INSURANCE PDUCY� OTHER TYPE TIDENN rl Y 0 BOND 0
OWNER'S INSURMCEWAVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that rrry signature on this permitappllcavon waives this requirement
CHECK ONE ONLY: OWNER❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT 1
hereby ceriify that all of The details and irrformauon I have submitted(or entered)regarding this application are true and accurate to the best of my 1
Knowledge and that all plumbing work and 1nstadations periormed under the perm issued for itis apptcafion wil in compliance wilt all Pertinent
provision of the Massachusets State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASH``t i��tit NAME. �v
I 6-se. vr' i l UCFSISE# at-3?a- IRE
COMPANYNAME7R,�.( 6-inrtvr .' ' :1),-.._L--�DDRESS: YC- �. per `Pr kri La H-(
cIlY7S1f'0u*- V STATE lAits zirt2-6 31 . FAX:
a 31:"?.- 3$S 71 0-ca1: 72Y-2-1?-1-o/( EMAIL:
MASTER 0 JOURNEYA —tP INSTAJIER 0 CORPORATION 0 4 PARTNERSHIP 0 LC❑
- ` S
OUG1[ r SF L ". . 017"
'11115PAGE;1r011INSPECTOR USI ONLY UINAL1.NS1'13C110N NO'I'ISS
'!01 k/is ex-G.PIt/aft / Yos No
THIS APPLICATION SERVES AS TI PERMIT ❑
FEE; $ - PERMIT(!
J'LAN REVD W NOTES