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HomeMy WebLinkAboutG-15-2995 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK crnr �ri18'u7�-1 .. MA DATE re I PERMIT# b fs- i10a �`1' JOBSREAODREssL.Ls�? __���-r'---L`� OWE►NER'S NAMYO Th 5EZ SD i lT OWNER ADDRESS rs4-i-1 . 'j K W ' : ' 1- 57 7/ FAK1 TY PE OR OCCUPANT'TYPE COMMERCIALL EDUCATIONAL E] RESDENTIALB PRINT 'CLEARLY NEW:Di. RENOVATION:0 REPLACE%ENT:0 PLANS SUBMITTED: YES 9 NO— APPLVWCES 11 FLOORS-• BSM 1 2 3 4 5 B 1 8 9 10 11 12 13 14 BOILER a CONVERSION ' • f DIRECT VENT HEA o' ; DRYER x - - FIREPLACE FRYOLATOR A FURNACE GENERATOR GRILLE _INFRARED HEATER LABORATORY COCKS ; MAKEUP AIR UNIT OVEN POOL HEATER ROOM SPACE HEATER - F ROOF TOP UNIT TEST UNIT HEATER ; - UNVENTED ROOM HEATER WATER •TER_ OTHER �'�hit NW NS 1111011110111110111111mmestra INSURANCE COVERAGE I have a current Jlablity hlstrance policy or Its substantial equivalent which meats the requirements of MGL Ch.142 YES N0 IIFYOU f f70EDYES,PLEASEINDICATETHETYPEOFEBYCIEQUNGDEAPPROPRIATEBOXBELOW many INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIWR:I am aware that the licensee does not have the insurance covinge required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives ads requhement CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Intonation I have submitted or entered regarding this application we true and&mutate to the best of my knowledge and that as plumbing wait and Installations performed under the permit Issued forthis application win be In kerne W II Partneri provb ipn of the Massachusetts State Plumbing Code and Chapter 142 ofthe General Laws. PLUMBER-GASH n I Eft NAME I l esk '£ a4c.. !LICENSE#'/Sgi SIGNATURE MP Q MGF[ JP 0 JGF© LP( [ CORPORATION D#t �-- ��fl PARTNERSHIPD fl LLC 0# owes l COMPANY NAME; -a< d '1Ii��[t1 s &23 � o,'ys / . uort`7`-� 1 CITY .0 STATEf H ZP�� Y r 1TEL 57e-477-1117 FAX CELLL✓57e0SD IEUANetre _L, _ I AUU 26 2014 60 L24 r �0'i'VfARTf ) .1/Old BIO '° _ - !v/e— vs4,'fit-71 6y2o)wuij • • 7. . �,,. . .