HomeMy WebLinkAboutG-15-3048 c �_ I MASSACHUSETTS UNIFORM APPLICATION FOR A YtKMI I IL) emit-tit-cal 1-.•.o rat 11V0-1 vnn
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W: y/a'�M6 114 MA DATE only PERmir#f106,-/stoslot 9.1
�'� JOaSITE ADDRESS- n OWNERS NAME -723(u�i C 57/1
GOWNER ADDRESS: y9 0241t1DVMw Oa •TEL' FAX
TYPE OR OCCUPANCYTIPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL❑ -
PR.=
CLL42L NEW:EV'''.RENOVATION:0 REPLACEMENT:0 PLANS SUBIv1 I I . YES 0 NO 0
APPLLANCES 2 FLOOR-. I ascot 1 1 2 3 1 4 5 6 7 1 8 1 9 10 11 12 13 14
I BOILER I I I
BOOSTER I I I
I CONVERSION BURNER I I I I I
COOK STOVE I
DRYER 'al
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FRY° ' 1°- DEC 01 2Q114 I I
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GRILLE MLILt'alrl �.
IN - . I r I
I LABORATORY COCK I I
1 MAKEUP AIR UNIT I 1
OVEN
POOL HEATER • I I
• 1 ROOM/SPACE HEATER I I
I ROOF TOP UNIT
TEST
HEATER 1 1 I I II III
UNVETI ED ROOM HEATER I I 1 I 1
WATER NEATER I I I I 1 1
T es .II I I I I
I I I I I I I I I I I I 1 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirement of MGL Ch.142 YES X10 ❑
If you have checked YES,please indicate the type of coverage8"-----
by checking the appropriate box below.
LIABILITY INSURANCE POLJCY Ly geOTHER TYPE INDEMNrF( 0 BOND 9
OWNER'S INSURANCE WARfER:lam 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 ❑
SIGNATURE OF OMR OR AGENT
hereby certify that all of the details and information 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 instllations performed under the pernul issued for this applicafion will be in compliance with all Pertinent
provision of the N,assachuse is State Plumbing Code and Chapter 142 of the General Laws. 4) ,/t(-4 .--
PLUMBS JGASI-I I i tit NAME: 0.14(-7,9?- Mfr. LICENSE#&)0.-4.? SIG IRE
COMPANY MIME NW, ftc -r fir ADDRESS: / CA/t-Agt..
CIN• '/AR4'Lro111,� STAT E /tlf ZIP: 074 73 • FAX
TEL: `fit& -7//6'331/CELL: EMAIL:
WASTER 0 JOURNEYMAN[24 INSTALLER 0 CORPORATION 0 a PARTNERSHIP 0 Lw❑g .
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(0�/ l0�/� � TIIIS APPLICATION SERVES AS TIIE PERMIT ❑ ❑
FEE: PERMIT a
PAN RREVIEWNOTI3S