HomeMy WebLinkAboutBLDG-15-005672 IIS UNIFORM AI'NLICAi Iul�! rurc.� rERvni i i L., Lr., .�,.,., , . • ....�-
.1 PERMIT# I'�'�Ib�5-0d57n7
hiA_ DATE:
JOBSI T EE ADDRESS: ? ? t/t I'm C Z ✓�[> OWNER'S11.y 1�fE A, /t rt Z i- lit z i
OWNER ADDRESS: TEL: FAX
TYPE OR OCCUPANCY TYPE COMIJER EDUCATIONAL ❑ RESIDE'!T IALNE '
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CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMI 1 I L U: YES❑ NO E
1 ",PPLIANCES-! FLOOR-- ; Esnt 1 1 ? 3 1 4 1 5 ; 6 ; 7 8 ; 9 ; 10 ; 11 ; 12 I 13 ; 14
1 BOILER 1 1 I I I I I I I 1
BOOSTER 1 1 1 I ; I I I I i
j CONVERSION BURNER 1 1 I ; I I I 1 1 1 i
COOK STOVE 1 I I ; I 1 I 1 1
1 DIRECT VENT HEATER I i I I I I I 1 I I 1
DRYER I I I I I I 1 1 I 1
FIREPLACE I I I I 1 I I I I I_
FRYOLATOR I ; i I I I 1 1 1
FURNACE I I I I I . I I I I
1 GENERATOR
1 GRILLE
INFRARED HEAL ti- I I I I I I I
1 LABORATORY COCK I I I I I !
MAKEUP AIR UNIT
Ion I I I I I I I I
I POOL HEATER i I • I I I I I I I
ROOM/SPACE HEATER I I I I I 1 I I ! !
I ROOF TOP UNIT I I I I I ! I I I
I TEST ! / I I I I I I I I
I I I I I I 1 1 I 1 I I
I I +AAA / I I I 1 1 1 1 I 1 I
MAY 15 2015 -V� I I I I I I 1 1 !
I I 1 1 1 1 1 1 1 1
r l .',..�._ Y T I 1 I 1 1 1 I I
{.` •N R. .._?d-T INSCE CO1fERAGE
a 1.L21 1 d1 L.LIAD.ItiN InS ce poky or its subs-antial equnralent urhich mee.:aye reGLifrerner6 of NIGL Ch.142 YES IO ❑
If you have checl-.e.d YES,please Indic to the type of coverage by g the approprias box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the I'iensee does not have the insurance coverage required by Chapter-IQ of the
i riassachusetts General Laws,and that my signature on this permitappficadon waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby eerily that all of the details and iniormaiion I have submited(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and inslIlations performed under the permit issued for this application will be in compliance with all Pertinent
provision of tie MlassachuseUs State PlumbingJ Code and Chapter 142 of the General Laws. 6. L
PLUMBERR11GASI-1I I tRNAME: _e_ /t - 5 vet✓L- LICENSE# /35 7//` SIGNATURE
P NAME: u cti_ f ` ADDRESS: `� 7 lam'` e ——/-)rc /�
COMPANY i� Q l y 1M P�(�
CITY: f.Va_�Ltta l STATE /4 ''1` DP: a 5-7 / • FAX: 5-°8Z?/C/7 '
TEL Soa24/ , 70 CFIL• 77y93c5057 EN1AL
Kim I ER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑4 PARl 1ERSH1.P 7= 11_C
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