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HomeMy WebLinkAboutG-15-1581 SSACHUSE1TS UNIFORM AerLILAI TUN rvnA rc WI yr v,.m .�.,.+ , ,l ,...., .n.,.,. =11111V4ti=f CITY: Vifia nirnF Mk DATE:0/AS PERMIT eth ls-tvr3'$/ JOESI FE ADDRESS: // Mt nit itkihr- OWNER'S NAME �.i/PPY F5i'c GOWNER ADDRESS' 11 ll�iki/,<i¢eiiy TEL FAX: TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0-- PR= ESIDENT IAL0— PR= CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:©i PLANS SUBM1 i I EL: YES 0 NO-0 APPLIANCESI FLOOR-. 1 Esrrlt 1 2 1 3 4 5 1 6 7 1 8 9 10 11 12 13 14 BOILER/O&L/�ri fiti j(Mlle BOOS GR I I I 1 CONVERSION BURNER 1 I I COOK STOVE I I I DIRECT VENT HEATER I I 1 DRYER IFIREPLACE I i FRYOLATOR I I I I FURNACE I I 1 . ' I I I I GENERATOR j I GRILLE 1 I I INFRARED HEATER I I ILABORATORY COCK MAKEUP AIR UNIT I I OVEN j I POOL HEATER j 'I I ROOM/SPACE HEATER 1 I I ROOF TOP UNIT TEST UNIT HEATER I I I ---- UN1D ROOM HEATER I I I WATER HEATER j j 1 ___1 1 I . 1 rI I I I I I I I 1 I INSURANCE COVERAGE I have a current fiabifmtiinsurance policy or its substantial equivaientwhich meas the req iirem erts of NIGL Ch.142 YES 210 0 If you have checked YES,please Mica the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Er OTHERTYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCEWAIVER:I 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this appbcauon are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under The permit issued for this application vwll in comp irgnce%wi*i all P provision of the Massachusetts Sidle Plumbing Code and Chapter 142 of the General Laws.4Y/ �l / eat PLUMBERIGASI-IiltttNAME. j1{4A 144A7'I'S,A/ LICENSE#L13?s"" SIGNATURE COMPANY NAME rt/1 yyWWCq at n RS 4 1.. ADDRESS:,erx tc� Crit': Se, _ DQ La4tOS STATE s pArS ZIP: eQ% FAX: TE1-(94 —O3)/ 01_62Y)7 --c/ C, R E C E R f E D 1 MASTER Zi/EURNEYh74,N 0 LP INSTALLER 0 CORPORATION 0 0 P44 SH P I❑'- G k]T :Pe x/17, 201k /(�/1 F tq'r,(2TMt� i iiv V OUGFI GA f SPEC_ i► s - CRISI'AGLFOR INSPECTOR USE ONLY INA ALINSPECTION NOTE'S Yes No — Tills APPLICATION SERVES AS TIIE PERMIT ❑ ❑ FEE: b PERMIT P PLAN RTVIlgW NOTES