HomeMy WebLinkAboutBLDG-15-003387 �� I MWSSACHUSETr'S UNIFORM APPLICATION FOR A NtKMl l l u rtru-utuvi 1.110 n I ,uvea vVLiISM
=F# CIT': Y /i0yy��VW, MAS DATE /246 21/ PERMRFfl1/fCO'9,3$V
�� JOBSI1EE ADDRESS: la /�l4i4 a /2r-cI OWNER'S NAME roS;77/ �4 Q uh iC
G OWNER ADDRESS: 98 25,700/4 Ad TE '?78-J34f-G3Q8 F
TYPE
OCCUPANCY TYPE .CIAL❑ EDUCATIONAL 0 RESIDENTIAL
ENT
CLEARLY NEIN:0 RENOVATION:COMM�REPLACEEMENT:0 PLANS SUBMITTED: YES 0 NO V
APPLIANCES1 FLOOR-. Bsmt 1 1 2 3 1 4 1 5 6 7 1 8 9 10 11 12 I 13 14
BOILER I I
BOOSTER I I I I
CONVERSION BURNER I I I
COOK STOVE I I I I
DIRECT VENT HEATER
DRYER I
FIREPLACE I I
FRYOLATOR I
FURNACE • I I
GENERATOR I I
I GRILLE I I I
INFRARED HEATER I 1 L I
LABORATORY COCK I I I I
MAKEUP AIR UNIT I I 1 I I
OVEN I
POOL HEATER I I • ,-1-:--77-----4
I ROOM/SPACE HEATER I I >+ r- G r 1 DI I
I ROOFTOP UNIT I I //00r� '7 I I
TEST UNIT _ I I I7d I i I
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UNVENTED ROOM HEATER I I I I t I I i
WATER HEAI�tt I I IRIm_oir4c oE4AR4t
1_ Tn
I I I � .-- I I
I 1 1 1 _ 1
I I I I I I
INSURANI COVERAGE
I have a current Benin;insurance policy or its subsatial equival- which meets the regterneris of NIGL Ch.142 YES NO 0
If you have checked M please indicate the type of covarag- • checking the appropria box below.
LIABILITY INSURANCE POLICY it OTHERTYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCEWANER I am aware that the licensee does not have the insurance coverage required by Chapter142 of the
` Massachusetts General Laws,and that my signature on this permit appUcadon waives this requirement
CHECK ONE ONLY: OWNER Q AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby tartly that all of the details and information I have subrrlbed(or entered)regardung this appIcauon are true and accurate to the best of my 1
Knowledge and that all plumbing work and installations performed under the permit issued for this applicsdon v I be h compfnn ..rtlnent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws
i- /
PLUMBER/GASHi tt/KNAME -723-7231715.641u7I LICENSE# /3‘24 SIGNATU
COMPANY NAME 1/9I✓ Gd oll Cozy ADDRESS: a.4 9S)o p
CITY: M '5ll�, STATE At ZIP: d24 3/ • FAX: /�'`t�p�
TEL • 7 .3r. Cal: a EMIL' �. � �/` kt(c
MASTER W JOURNEYRAN 0 LP INSTALLER 0 CORPORATION 0 t PARTNERSHIP 0_ LLC Q
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',U1119PAGE FOR JNZICCI'OI[USEONLY JnNALINS I'EC17ON NOTES
ff Yes No.111:, �T _7) TI IIS APPI-ICATION SERVES AS TI IE PERMIT ❑ ❑
/UQ
PEE: x_ _ PERMITG
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