HomeMy WebLinkAboutBLDG-23-008787 "` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK
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CITY: 4A. Y/104044 MA. DATE PERMIT#g i-DG-2-`---21 7
JOBSITE ADDRESS:/0111 M ri 1-3 OWNER'S NAME:
G OWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIALZ EDUCATIONAL ❑ RESIDENTIAL 0
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Z PLANS SUBMITTED: YES 0 NO IQ
APPLIANCES'i FLOOR-) Brant 1 2 3 _ 4 5 .6 7 8 9 10 11 12 .13 14
BOILER
_
BOOSTER
_CONVERSION BURNER
COOK STOVE r
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR - _ .
_FURNACE
GENERATOR
,,, GRILLE
INFRARED HEATER .
W LABORATORY COCK ^
MAKEUP AIR UNIT
4 OVEN q
POOL HEATER
ROOM!SPACE HEATER •
,1 ROOF TOP UNIT -/
t TEST I l Kr C E I u .E. D
Z UNIT HEATER
Lu UNVENTED ROOM HEATER
WATER HEATER MAY 1(r?llf3
al 1t DI i rlFPAR rVIENT
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By:
INSURANCE COVERAGE �—
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 21 NO 0
If you have chested yg ,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY,] OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee ilgeaggibilg the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application lyalveg this requirement
CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER ORAAENT
hereby certify that all of the details and information I have submitted(or entered)regarding this epptcallon 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 be in oompNance with WI Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTER NAME: 7a 01)2- Co 9Y " LICENSE# %SRO 7 SIGNATURE
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COMPANY NAME: VII Z C. ,ADDRESS: / y k C /f o- S
CITY: NW f STATE: Ji ZIP: 6?-7k. FAX:
TEL: 771 S b3 tat 1 CELL EMAIL: —S,+✓ ►'Pori 3 e.5Af' ►1, l,.a+—
MASTERY JOURNEYMAN 0 LP INSTALLER❑ CORPORATION 0# PARTNERSHIP❑# LLC❑#
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