HomeMy WebLinkAboutG-14-1078 �� MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT lO PtMrurcm WWWaa rt t i uvm._vvvurcn
. • sarr CITY: Vi eoc hoar' Mk DATE 6720 4/111 PEP.Mrr bk-/D7g
�"'ff JOPSriEADDRESS: (G1 THait. Ctt 3nog 7ftn OWNER'S NAME C' et COIN
�T OWNER ADDRESS- TEL FAY:
P PE OR
OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 13
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[" PLANS SUBMI I I tU: YES 0 NO❑
APPLIANCES1 FLOOR-i• I Bsrnt 1 1 2 3 4 1 5 1 6 1 7 1 8 9 10 1 11 1 12 I 13 1 14
BOILER I I I I I I I I I
BOOSTER
CONVERSION BURNER I I I I I I I I I
COOK STOVE
I
DIRECT VENT HEATER I I 1 I I I
DRYER I I I I I
FIREPLACE I I I _ I I
FRYOLATOR I I I I I I 1
FURNACE
GENERAGRILLE
70R I I I
INFRARED HEATER I I I I I I I I
LABORATORY COCK
MAKEUP AIR UNIT I I I I I I I I
OVEN
POOL HEATER I I • I I I
ROOM/SPACE HEATER I I I I I I
ROOF TOP UNIT
TEST I I I I I I
UNIT HEATER
UNVENTED ROOM HEATER I I I I
WATER HEATER _
• F.) -. rr , , , r- n \
I I I 11 I l —I—I 4 1
INSURANCE COVERAGE I 11111 24 IIlb 1, 0
1 have a current liability insurance policy or its substantial equivalent which meets the requirements M PLC 142 0
it
if you have checkedILplease indicate the type of coverage by checking the appropriate box below r31 ',t i a��, u� ��ry�H��yqtpr r
LIABILRY INSURANCE POLICY IEV OTHER TYPE INDEMNITY ❑ BOND 0 Pe.0
OWNER'S INSURANCE WAIVER: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 appfcadonwaives this requirement
- CHECK ONE ONLY: OWNS 0 AGENT 0
SIGNATURE OF OWNS OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this appficauon are true and acotrate to the best of my
Knowledge and that all plumbing work and installations performed under the pemrd issued for this application will be incompliance with all Pertinent
oration of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASI-1i itxNAME: 11,A,rcft- Maw LICENSE# •3?O 3 SIGI RE
COMPANY NAME: &A T. Pr< t NTS ADDRESS: / Cpm 0-1 Lti
CITY: Li- tr^-n^tnn STATE Oda ZIP: 626'7.3 FAX
TEL: CELL: Sats a46 33k-, EMAIL:
MASTER❑ JOURNEYMAN 0"!P INSTALLER 0 CORPORATION 0 g PARTNERSHIP 0.4 ac❑# .
LP ON • ItS ,}'11I91'AGEFOR JNJ'JtC1'OIIU,SCsONLY ��INALI.NSI'ECTIONNOTI�S
OUG( Vas No
THIS APPLICATION SERVES AS TIIE PERMIT ❑ ❑
FEE: S PERMITS
FLAN REVIEW NO113ES