HomeMy WebLinkAboutG-14-1027 RECEIVED
__ .. MASSACHUSETTS UNIFORM APPUCATIONFOR APERMIT TOPERFORM • .FITTING WM:ULU
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• JOB& EADDRESS193 La.z o Rile �i/Vr) . - IOWNER'staAMEl Pr. -4:el JPm kn I •
Ly owNERAGGRESS I ' ITErn 4i7-O€ 3OIFAX • .
IME OR -OCCUPANCY TYPE CCIMEZCW 0 - . -EDUCATIONAL0:
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43Zniar NEW:0 REN OVATIOM It .REPLACEMENT- . Q . PLANS SUB/SI-TED: TESL] NOEL .
APPLIANCES 7 FLOORS-, RSV 2 3 41 5 6 I 7 6 9 10 n 2 1 17 14
BOILER _ _ - _ H
BOOSTER . - -
CONVERSION BURNER aniiiiir
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WOK STOVE.
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DR
E N VENT HEATER _
FIREPLACE ' •
FRYDLATOR
FURNACE . g Bag
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GENERATOR • ' -
GRILLE O t,lraa D E {/1) -
LHEATERi. soma • t
LABORATORY
• MAKEUP AIR UNIT
OVEN • __ _
POOLNEATER .._ ti _ 1
ROOM/SPACE HEATER sum J
ROOF TOP UNIT IS
-TEST
! UNITHEATER1
UNVENTED ROOM HEATER
WATER EA la' 1 1�-
OTHER Mtn e.alt intiMarnein- - 1
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QNSURANCE COVERAGE •
Ihave aanent liability km:raneepolicy or Dssubstamid equivalent which meets the requirements ofVOL Ch.142 YES WINO ❑
I Eyou othsontsmnsouscanunnypEor••• m; ci BY CHESNGTHEAPPROPRIATEBOXBEIDW
LIMW(ILSURANCEPOUCY M. art RTYwwmaifMW Q BOND 0 -
OWNER'SQNSURANCE WAIVElt I am awe Cat the 8catsee doesnot have the imarance coverage respired 67 Chapter 142 of the:_
MasadaaettzGenera lLaws,andthatDrysig�9eonthisP�app t --
• CHECK ONE ONLY: •OWNER Et AGENT 0
- SIGNATURE OF OWNER OR AGENT - -
Iearthy cagily tea alpiths deb*ad r4Omoelloe I have submitted or entered seg.dIg ails,1a.J . .e true and emirate b thehest of my tatooiedge
and that as punting waked Yailaaagorm pestered older the permaireued locals SR be it mpg Benue el provisionof the
Massachusetts Slate Plumbing fSde/.d Chapter 142 caw Gaal Laws. /J:s/'
PUNMBERtITTER NAME Iliov MCRr;Ja - ILtcaNSE 175SIGNATURE
14PElMGFQ -IP 0 .IGF.Q LPGIQ CORPORATION[71# ;%t C. PARRIERS1WD#1 (Lie QI '
tZUPAN?NAI4F-4g„*"MC.&:dL Mom-1-Itea(,in4ADDRESSI II railesrd P0A
•ow I in Ynemen fii. - ^.._1 I STATE plA IMPI 4A67.- r I ( o&)�$-456t - I ,
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