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HomeMy WebLinkAboutG-14-781 MASSACHUSETTS UNIFORM APPLICATION FOR A PERI ` q Y: Y0.21.^n,ow MA DATE ab 7)11f PEANUT# /y-777 GJOBSrTE ADDRESS. c 3 W(1 FI'U OWNERS NAME (A 4e.191' \Y.A.) G OWNER ADDRESS: ,S TE6b93cia-a6-61Fm: TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL® PRINT CLEARLY NEIN:gi RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ APPLIANCES? FLOOR-• Bsr,Y 11 2 3 1 4 5 1 6 7 1 8 9 1 10 1 11 1 12 I 13 I 14 1 BOILER BOOSTER I CONVERSION BURNER I I I I I I I COOK STOVE I I I I I I DIRECT VENT HEATER I I I I DRYER I FIREPLACE FRYOLATOR I I III I 1 FURNACE I 1 I I I 1 GENERATOR I I I GRILLE I I I I INFRARED HEATER I I I I I LABORATORY COCK I I L I I • MAKEUP AIR UNIT I I 1 I I OVEN I 1 POOL HEATER I I ROOM/SPACE HEATERI 1 ROOF TOP UNIT 1 I I I I TEST I I I I I I I UNIT HEATED. I I I 1 UNVENTED ROOM HEATER I I I I I I 1 I WATER HEAT I I I I 1 I I I 1 I I I I I I 1 II, 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equnralentwhich meets the requirements of MGL Ch.142 YES 0 NO 0 If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LABILITY INSURANCE POLICY p OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAVER_I arta aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and thzt 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 and information I have subrrutthd(or entered)regarding this application 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 will be in compliance with all Pertinent provision of the Massachusetts Stale Plumbing Code andnChapter 142 of the General Laws. q ,v €_ / PLUMBERIGASI-II tit NAME_ 2nAPR'?rfnt l car rt-1 LICENSE#/DflO1 �CrP✓1SIGNATUREK cd'� COMPANY(NAME1))10t�n , (fi -,Q Cly- ADDRESS: i J-1 b�.R Y/2. an: SLive_wsb -412_1 STATE �IA LP: ©ic c • FAX: TEl#S1cf�{o2-o/sv OCELI( 0$6`7i-S53R sJAIL MASTER 51 JOURNEYMAN❑ LP INSTALLER❑ CORPORATION 0# P;uRTNERSRP El c E V EEP4 FEB 18 201,4 1 i s Y-A—Ta 41/f pUGE GA ,I" - •PI • ; • THIS PAGE EOR INSPECTOR USE ONLY VIN ALINSPECTION NOTES .64' a 45 .dec. /f f Yes No THIS APPLICATION SERVES AS TIIE PERMIT ❑ ❑ FEE $ PERMIT PLAN REVIEW NOTES • --t