HomeMy WebLinkAboutBLDG-16-002300 MASSA - USETi S UNIFORM APPUUAi IUN rurc:a r rcrr i
CI1`: (rarr►.w-tt Mk DATE: ru-to- it PCPIJdT- 1
JOBSITE E ADDRESS: 2 12 IC Yo;r4,L Ce`'{C/ O\WNER-S N.AME a
Nor
OWNER ADDRESS: I 11 I L. Pon d- Oct TES__' FAX •
TYPE OR OCCUPANCY'TYPE: DOMME:CAL E EDUCATIONAL [Z RESIDENTIAL❑
P 1
CLEARLY NEW:❑ RENOVATION❑ REPLACEMENT:E PLANS SUBIAI I I HY. YES❑ ND❑
1 APPLUANCES7 •FLOOR I Sent 1 I 2 3 I ' I 5 I 66 17 8 1 9 1 10 111 12 I 13 I 14
I BOILEP. I I
1BOOSTER I 1 I I I I I I I I
I CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATERI i I I I I I I I
DRYER
FIREPLACE I I I I I I I• 1 I I_
FRYOLATOR
FURNACE I I I I . I • I I I I I
GENERATOR I I I I I I I I I
I GRILLE
INFRARED HEATER I ! I I I I I I I I I
I LABORATORY COCK I I I I I I I 1 I I I
I IVIAICEUP AP.UNIT I I I I I ! I I I I I
101/Ers
1 FOOL HEATER. I I • I •I I I I I I I I
ROOM I SPACE HEATER
I ROOF TOP UNIT I I I I I I I I I I
I TEST I I I I I I I I I I
I UNLIT HEATER I I t I I I I I I I
UNv >=D ROOM HEATER ! I I I I 1 1 1 1 1 1
WATEr.hEATER 1 I 1 I 1 1 !
I I I I I 1 1 1 I ' I 1 1
- I I I 1 !
I I 1111111111
1 1
INSURANCE COVERAGE
I have a current Iiabliity insurance policy or its substantial egr3itiralent which mew c the regufre-nents of NIGL Ch.142 YES e(NO ❑
if you have chid Y ply{indicate the type of coverage by cbeclaing the appropria3 box below.
L1ABDJfl INSURANCE POLICY OTHER TYPE INDEMI Y 0 BOND 0
OWNER'S 1NSU NCE WANFR:I am aware that the licensee does not have the insurance coverage reed by Chapter ia3 of the
MassachuseLe General Laws,and that my signature on this permit applicadon waives this requirement
CHECK ONE ONLY: OWNER❑ AGENT ❑
SIGNATURE OF 01NNi=R OR AGENT
hereby cerily that all of to details and information 1 have subrrirded(or entered)regarding this appilcaiion are true and accurate tote best of my
Knowledge and that all plumbing work and instillations performed under are permll issued for this appliraiion will be in compliance wish all Pertinent
provision of tie Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASi-i l I hXNAME: f vlarIf_- D iSeruc4-4-4 LICENSE# /r2 r--e SIGNATURE
COMPANY NAME: M - tom+ H ADDRESS: •P a• 116,t /9 Y Z-
CITY: 5. Oe•,°; STATE f ZIP: O Z fi 6 v FAX:
TEL: CFI 50,6 3 yy 4/9/6 EMAIL
MASTER.jr JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑74 1 ❑`
I OCT 2.�2015
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