HomeMy WebLinkAboutBLDG-15-001394 •—t---It-•• I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GA5 Fu I LNG WORK
`ee art: y armo u-A-Lt MA DATE RAZ to//4 PERMrrr/✓'dv15--0O/ref
✓ JOESrrE ADDRESS' CI C} 1% FWt. OWNERS NAME 4,3 i r e%)
G OWNER ADDRESS: 9 Gi I I (R vo TEL• FAX
7YPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRDTT
CLEARLY NEW:V RENOVATION:❑ REPLACEENT:0 PLANS SUBIv1 i I - YES 0 NO PI
APPLIANCESI FLOOR Bsmt 1 1 2 3 1 4 5 6 7 1 8 9 10 11 12 13 14
BOILER I I I
BOOSTER I
CONVERSION BURNER I I
COOK STOVE I
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE I
GENERATOR
GRILLE
INFRARED HEATER i !
LABORATORY COCK I I
MAKEUP AIR UNIT I I
OVENI
POOL HATER • I
1 ROOM/SPACEHEATER I I I I
I ROOF TOP UNIT I I I I I
TEST I I I I I I
UNIT HEAL. TE8,530440
R I I
WATER I-EATER* Him
mL I I I I I 1 1 I
1 . 1
j 1 I
INSURANCE COVERAGE
II I I I I I I
I T t - ,- poky or its substantial egnivalentwhich meea the requirements of MGL Ch.1A2YES �O ❑
have checked Y_ES please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER T YPE INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachu sdIS General Laws,and that my signature on this permit appl1 on waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby army that all of the details and information I have submitted(or entered)regarding this app6raiion are true and accurate to the best of my
Knowledge and that all plumbing work and fnsallalons performed undertie pemuf issued for this application wID be in compliance wit ail Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGAS'riI rtKNAME Pau I Chart GV1 LICENSE# I T)ro SIGNATURE
COMPANY NAME: C, etr r O vt P I a nn Oi t n D ADDRESS: 140 ✓A aple lav 2
CITY• 13 r I o19 e w o.+r.r STATE Irvt+4 ZIP: 0 a3,D FAX
TEL' (-79'1)Ta G - (,/rb CELL EMAIL:
MASTERJOURNEYAMIN❑ LP INSTALLER❑ CORPO.RATIONaT 53 TT PARTNERSHIP 04 us
Gee
OUGC[ Y
PE , 0 ' 4g • 17115PAGE FOR INSPECJ'ORUSEONLY PIN ALJNSI'ECJ90NNOTISS
R6711- 6a en l roe- - a,' � Yos No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT
J'LAN RJ,VI1C\Y NOTES —
Fold,Then Detach Along All Perforations
i Fe" COMMONWEALTH OF MASS-ACHUSETTS-$.1
r, DIVISION OF PROFESSIONAL LICENSURE
BOARD OF
PLUMBERS AND GASF J TTERS'/,
ISSUES THE FOLLOWING- LICENSE
LICENSED. AS A_MASTER PLUMBER.
( 'N I..
PAUL4R CHARRON t''
S,140 MArLEwoR .7,- .".•,4. '•,- '1, 1.&L„ (..),,--6 , ' 6 '
tt OR 1 DGEWATER, "--:°:14A 02324-2525
L 15686 ,•' r 135/01/16''.-t- 212587
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