HomeMy WebLinkAboutBLDG-15-000940 MASSACHUSETTS UNIFO AYruc. uv r • _
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cfvno44% MA. DATE: Q'a7.14 PERMfiz�116^/3'-Ci:'o`��♦
JOSSITEADDP.ESS: 40 �g}C'he( Skate-0 OWNER'S NAME:;'ahh arev,"CA(
GOWNER ADDRESS. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCLAL❑ EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES-. FLOORS Bsnt 1 2 1 3 1 4 5 5' 7 1 8 1 9 10 1 11 1 12 13 1 14
BOIL
BOOSTER I I I I I I
CONVERSION BURNER I I I I I I
COOK STOVE I I I
DIRECT VENT HEATER I I I
DRYER 1 1 I I
FIREPLACE I
FRYOLATOR I I I I I
FURNACE ' I I
GENERATOR I I
GRILLE
INFRARED HEATER I I
LABORATORY COCK I I I I I
MAKEUP AIR UNIT I I
OVEN I
POOL HEATER I I I I
ROOM/SPACE HEATED I I I I
I ROOF TOP UNIT I I
TEST
UNIT HEATER I I I I
UNVENTED ROOM HEATER I I I I
WATER HEATER I I I I I
I I
I I
INSURANCE COVERAGE
I have a current fiabwM insurance policy or its substantial equivalentwhich mg"the requirement of MGL Ch 142 YES CNC 0
If you have checked YES please indicate the type of coverageerby checking the appropriate box below.
LIABILITY INSURANCE POLICY G‘ OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCEWAVER 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❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of The details and'vliormauon I have submit d(or entered)regarding ibis application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed underlie permit issued for this applicafi wi l be in complancwith all Pertinent
provision of the Massachusetts Sia Plumbing Code
and Chapter 142 of the General Laws.�r+ 0 5�--
PLUMBERIGAS1-11 hKNAME: \L-1Q.. \' aeat'^S LICENSE# ?Weil SIGNATURE
COMPANY NAME �5,eAc Gc.s .& UV WR- ADDRESS: IR 4 4 oo 11 TR. l ►✓` i
CI1Y:)« Ser, rte- STATE 1 __ 21P. C3PC03 1 FAX:
TEL c_/tole 31 CELL' EMAILL7
MASTER JOUP.NEYhM1N 0 13 INSTALLER❑ CARPORAI1ON❑ PARTNERSHIP 0= +u❑17.
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• OUGkL GA N.l'LC'. ��
9 y�y Yos No
!, 7 TI IIS APPLICATION SERVES AS TI IE PERMIT ❑
FEE: $ PERMIT U —
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