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MASSACHUSETTS UNIFORM APPLICATION FOR ANtKMt1 turtKtvtuv+uvaniuvurv�rtn
CITY: VA12 Wo (j r -N � NiAA. DATE I ''7yPPERmrrrrL//�b-irCV!Y 1
JOESII'E ALIDP.ESS: L f���CtDl�f-- 2�� OWNETS NAME L ���-j•7 C TES T Wr `
OWNEP.ADDRESS* C / ` TEL
OCCUPANCY TYPE COMMERCIAL F'1 EDUCATIONAL ❑ P.ESIDENTIAL
NEIN: Z� RENOVATION: REPLACEMENT. ❑ PLANS SUSIv1 1 ED.• YES ❑ NO ❑
APPLLANCES7. FLOOR- I Bsnr, 1 1 1 2 1 3 1 4 1 s ° 1 7 1 8 1 9 1 10 111 112 13 I 14
BOILEP,
BOOSTER I I I I I I I I 1 I I I I I I I
CONVERSIONSUR4ER I I I I I I I I I I I I
COOKSTOVE
DIRECT VENT HEATER I I I I I I I
DRYER I I I I I I I I I I I
FIREPLACE I I I I I
FRYOLAT OR
FURNACE
GENERATOR I I I I I I I I
I GRILLE
INFRARED HEATER I I I I I I I I
LABORATORY COCK
I I I I I I I I
MAKEUP AIR UNrOVEN
I I I
Poo HEATER I I I I I I I I I
ROOM / SPACE HEATEP, I I I I I
I ROOF TOP UNT I I I I I
I TEST I I I I I I I
UNIT HEATER. I I I
UNIT ROOM HEATER I I I
WATER HEATER I I I I +
I 1
k6 a' II I I 1 1-
(1'l0
INSURANCE COVERAGE
I have a current Rab insurance policy or its substantial e#%rdlentwlvch meas the requirements of MGL M142 YES NO ❑
If you have checked YES, please indicatethe type of COVBTBqe by checong the appropriate box below.
IJAB11MMSURANCEPOLICY OTHERTYPEINDEMNRY ❑ BOND ❑
OWNER'S INSURANCE WANER:1 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 ❑
SIGNATURE OF OWNE .OR AGENT
hereby carmy that all of Ste details and information 1 have subuked (or entered) regarding this appficafion are true
Knowl=..dge and lfiat &I plumbing work and installations performed under t ie pend issued for this app8aft virtu
provision of 4te Massachusetts Stare Plumbing Code and Chapter, 1/42 of the General Laws.
PLUMsmGASFITTERNmeAy4 � - �C IRS LrENSE#
COMPANYNAME: 017MLIu C ADDRESS: V ���(�n�
CITY Wu7-1I/ STATE jj�±L ZIP: Q2
FAX
TEL: 17D`a"_L' - Y�Q CEI EMAIL•
MASTER ❑ JOUP.NE UAN V(�31NSTALLER ❑ CORPORATION ❑ 9 PnUN-E.S41? ❑ = L ❑
OUG G
l 81!1 " 1
RIoN ��s okh`
11'111,9 PAC,—Cl IfOl INUNCE011 USE 0
Yos No
THIS APPLICATION SERVES ASTHE PERMIT ❑ U
FEE: E _ PERMIT A
rL ANI1rVIr1YN0'1'rS
V IAL I.NSI'PCI'ION NO'I'ISS