HomeMy WebLinkAboutBLDG-16-002968 v ti I MASSACHUSETi S UNIFORM APPLICAI IUN rUrc r,rt=mutt 1 1 v nr .,r
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a y.ft CITY: Mk DATE:4/. PERMfl=.`PY-496-lb-15,d,„-zq6e
JOESITE ADDRESS: O\MqE?'S I'L JvrE 44/TA ..44e7400eLY
11 i'' 1 ( OWNER ADDP.ESS: lil#W,W TEL: FAX:
TYPE Or OCCUPANCY TYPE COIMIJERC AL❑ EDUCATIONAL ❑ RESIDENTIAL'
PRTh1
CLEARLY NEW RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO D
I APPLIANCES? FLOOR-+ I Bsrt 1 I 2 3 I 4 I 5 I o I 7 8 I 9 I 10 111 I 12 I 13 I 14
I BOILER I I I I I I I I
BOOSTER I I
CONVERSION BURNER I j I I I I I I I i
COOK STOVE I I I I I I I I I
I DIRECT VENT HEATER I i I I I I I I I I
DRYER I I I I I I I I II
FIREPLACE I I I I I I I
FRYOLATOR I i I I I I I I I I I
FURNACE I I I I I . • I I I I I l
I GENED,ATOR I / I I I I I I I I I I
I GRILLE
INFRARED HEATER I I I I I I I I I I I
I LABORATORY COCK I I I I I I I I I I I
ITVJJPAIRUNIT I I I I I I I I I I I
IOV I I I I I I I I I I
1 POOL He-ATr'R I I •I I I I I I I I
ROOM/SPACE HE4IER I I I I I I I I 1 I ; .
I ROOFTOP UNIT I I I I I I I 1 1 I I
I TEST I I ► I I I I I I 1 1
1 UNIT HEATER ' I 1 I 1 1
I UNVEN ID ROOM HEATER I I I I I I 1
I WAILET HEAT I I I I 1 1 1 1 ' 1 1 1
I I I 1 I I 1 1 1 1 I
I I 1 1
I INSURANCE COVERAGE
I have a current Liability insuance policy or its subs al el uivalentwhich meet The requirerner,;s of NIGL Ch.1 12 YES NO 0
If you have ch l;ed Y3,ply{indicate the type of coverage by checking the appropri box below.
LIABILITY INSURANCE POUCY-43 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER:I am aware Lathe the limns ee does not have the insurance coverage required by Chapter 142 of the
Rriassachusetts General Laws,and That roy signature on this permit appkadon waives this requirement
CHECK ONE ONLY: OWNER❑ AGENT ❑
SIGNATURE OF OWNER.OR AGENT 1
hereby carmy That all of the details and informaiion I have submitted(or entered)regarding this apptca ion are true and accurate to the b:.y of my I
Knowledge and tat all plumbing work and instailations performed under the pernut issued for this appl cdon will be in compliance vAin;,./ ..anent
provision of The Massachuse s State Plumbing Code and Chapter 142 of The General Laws. d.fX11.
PLUMBER/GASH I I R NPJ/iE:zz-Tioul p CA 2120*LICENSE#'3 1?-S3' SIGNATURE
COMPANY NANi)= 4,QOe9A5 4M/✓L-5rn R3(/I)<=;ADDRESs: a-0 D v. /✓✓S f O J9 VD
CITY: 4 Y!/4Y/.$ STATE �� ZIP:Q do/ • FAX: -
TEL: s $ g°f,S(� CELL: 17JIAiL'
MASTER❑ JOURNFYk4AN430 LP 1NSTA I ❑I CORPORATION 0 4 PARTNERSHIP❑= 1 C
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NOV 3 2O15
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