HomeMy WebLinkAboutBLDG-15-006424 IM1ASSAGHUSEET S UNIFORM APPL1C:Ai:uN rum r=rivii 1 I v r=.n1-,,...,, urn , „ „.•- .t�....ti
CITY: o- M DATE Pt-'r IJiT= !J/5'De �`Z�
JGES i t ADDRESS: OV \!)='R'S NAME:it#4_-27,/,_?-G 32
1 G OWNER ADDRESS: L:'I.-Ati a: PA^ /
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TYPE Ot OCCUPANCY 1'PE COM ME,CL L❑ EDUCATIONAL ❑ PESIDEI�T IAI ]
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CLEARLY NEW:❑ RENOVATION:D PEPLACEMEN i;�" PLANS SUBMITTED: YES❑ NO
I APPLIANCES? FLOOR- 1 Bsmt 1 I ? 3 1 4 1 5 1 6 1 7 8 1 9 110 1 11 1 12 1 13 I 14
I BOILER
BOOSTER 1 I I I I I I I I I I
1 CONVERSION BURNER I I I I I I I I I I 1
COOK STOVE I ! I I I I I I I
I DIRECT VENT HEATER I i I I I I I I I 1
1 DRYER I I I I I I I I I I
FIREPLACE I I I I I I I I I
FRYOLA l OR _! ! I I I I I I I
FURNACE I I I I . I I
GENERATOR
GRIME I I I I I I I I
INFRARED HEATER I I I I 1 I I I
LABORATORY COCK I ! I I I I I
MNCEUF AIR UNIT
I OVA I I I I I I !
POOL HEATER I I •I I I I I I
ROOM/SPACE HEA T EP, I I I I I ! ! •
ROOF TDP UN]T I I I I I L I I
I TEST I ! I I I I I I
UNIT HEAT-, I I I I
UNVEt\TIED ROOM I-iEATER I I I ! 1 I I I I
WATER HEAT . I I I .•
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I I IIII I I I
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I I I I L I {I � 4} is I : I,•,'
INSURANCE COVERAGE
I have a current liabilb insurance policy or It substantial equivalent which m the requiremer of NiGY Ct 19 1 (!❑,U ❑
if you have chat-mod YES,please indicate the type of coverage by checking the appropriate box below- ((J
LIABILITY INSURANCE POLICY 0 OTf TER TYPE IIWaliMITY ❑ BORID ❑ IJd, oil/;
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OWNER'S NSUR.AI�CE WAVER:I am aware the the license.does not have the insurance coverage required by Chapter'142 of the
Wriassachuse-as Genarcl Laws,and that ray signature on this permit appbcadon wakes this requirement
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWRER OR AGEN T
hereby cer t y that all of the details and irriormation 1 have subrriried(or entered)regarding this app1caiion are true and accurate tithe best of my 1
Knowledge and tat all plumbing work and instellailons performed under the permit issued for this applcaiion will be in compliance with all Prrlinent
provision of The Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLU MBERIGASLI I I tR NAWI1 ./f7� //er—//(j LICENSE#,A 0/7 'TIRE
I�COlv1PA Y NAIVES ADDRESS:
CITY: / v'fif P/M STATE#4.__ DP:a 1 " % FAX:
M:As 1 iR D JOURNEYMAN❑ LP INSTALLER!=1 CORPORATION❑ P AR NE c:I=P❑= Imo❑
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