HomeMy WebLinkAboutG-14-759 -.� _' `-- MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFO
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JOBSITE ADDRESS- /0 7/f 1 1sWNER'SNAME: G%'? S /(6/I46'GV
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TYPE OR OCCUPANC TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
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pr CLEARLY NEW: RENOVATION:❑ REPLACEMENT:0 PLANS SUBMI I I ELI: YES 0 NO Q/
APPLIANCES( FLOOR—. ssmt 1 1 2 1 3 1 4 5 6 1 7 1 8 9 10 11 1 12 13 14
BOILER 1 I I I I I
BOOSTERI I I
1 CONVERSION BURNER 1 I I I
COOK STOVE I I I I
DIRECT VENT HEATER
DRYER I I I I
FIREPLACE
FRYOLATOR I I I I
FURNACE 7 1 I I I
GENERATOR I I I
GRILLE
INFRARED HEATER I I I
1 LABORATORY COCK I I I 1
1 MAXEUP?JR UNIT I I
OVEN I I
POOL I-(EATER • I
ROOM/SPACE HEATER I -
1 ROOFTOPUNIT I I L
TEST I I I I
UNIT HEATER. I I I I
I UN'VENiEI D ROOM HEATER I I I I
I WATER HEATI I I I I I I
II- I I I I I
I I I I I y I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the regwemeris of!JiGL Ch.142 YESAI NO 0
If you have checked YES,please indicate the type of coverag by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHERTYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WANFR 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 ❑
SIGNATURE OF OWNER OR AGENT •
hereby certify that all of the details andinformationI have submitted(or entered)regarding this applcaiion are true and acuate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this applca5on will be in 1.fiance with a➢Pertinent
provision of the Massachusefls Statee��Plumbing Cod,Chapter 142 of the General Laws. Q ` ;s
PLUMBERIGAS1-11 I tRNAME(JIO.�, "7t*' / LICENSE4 76' / SIGNATURE
COMPANY NAME/�.c�G dat < v/6 ADDRESS:f"O`76041a/0 S—
Cfty:ria �LI�Lia> STATE•r4 ZIP:a4-7, FAX
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MASTER 0" JOURNEYMAN❑ LP INSTALLER 0 CORPORATION❑4 _n ertNE.,stup D I e•JPV
FEB 10 2014 In
BU DI !1 'ARTME T`'^'
BY.
AUG S NL 1' ► 9 r, ' L'II.L91'AGEFOR INSP_ECTORUSE ONLY FINAL INSPECTION NOTES
'4/I- W4 G L�2 /f _ // /� Yos No .
THIS FlPPLICFlTION SL"RV�S/1S TIiG PERMIT ❑ ❑
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FEE: PERMIT
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