HomeMy WebLinkAboutBLDG-23-9419 - ~
MASSACHUSETTS UNIFORM APPLICATION FOR A PE MIT
CITY MA DATE
TH
OWNER ADDRESS TEL FAX
TYPIE OR --t'l
PRITqT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL
CLEAR-LY NEW: RENOVATION: REPLACEMENT: PLANS SUBM'ITTED: YE--S 1�0
BOOSTER
CONVERSION BURNER
COOK STOVE
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCK'S
' MAKEUP AIR UNIT -
' ��� 1-4 ^Y�q -
OVEN - --
POOL HEATER I)PPART^w--'
ROOM/SPACE HE/�TER / / ' | e'', -- —'
ROOF TOP UNIT ----' --__- -------------|
TEST
UNIT HEATER
UNVBNTEDROOMHEATER
vmHERHEATER ---- ---�
OTHER
-
|have eour�n insurance policy mrkseu6mtanba INSURANCE COVERAGE
�~requ'^�°" Ch.i42 YES ���n F�
||F YOU CHECKED YES,PLEASE INDICATE THE TYPE OFC '^"
~`�.^"= CHECKING THE
. L��BiUTYi�8URA�CEP�L�CY �� // OTHER TYPE INDEMNITY BOND
OVyNER'3 |NSURA!4CEUVA|VER: | am�aware that the licensee does not have the inoum»u»coverage'aqoimdbYChu�er142ofthm
--
' Massarhusetts General Laws,and that my signature on this permit application waives /
this requirement.
SIGNATURE OF OWNER ORAGENT CHECK ONE ONLY: OWNER [I AGENT E]
|and that all hereby certify that all the details and information I have submitted or entered regarding this application are true and accurate to the best ofmyknowledge /
~� Mau uh .--etts ��bin" '~'~~'~^'"`="�"""uv�nnnnaounuev�epem�biou��h�VWsopp|i��o mi||b � � prov
on ofthe
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PLUIABER GAS ITTER NAME I_--*- LICENSE SIGNATURE