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HomeMy WebLinkAboutBLDG-22-9598 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT A t-1.434: TO PERFORM Gsz errnw±WORK CITY: A f) / 1 //�yy MA. DATE:(./C PERMIT# VAX- z 1-q 5- ;V JOBSITE ADDRESS: ,7 ! 13 f t)Sh H I'' fd OWNER'S NAME l l I I ee T GOWNER ADDRESS: TEL: �� TYPE OR FAX: OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENT CLEARLY NEW:❑ RENOVATIONS REPLACEMENT:❑ PLANS SUBMI 1 I tD; YES❑ NO[] APPLIBOILER NCES1 FLOOR =-©®0 5 6 7 8 9 10 11 IN® BOILER =_—��—�-- BOOSTER ____ CONVERSION BURNER _ �IMEMIIMMINIII_=a==-_ DIRECT VENT HEATER —COOK STOVE �_— �----_= FIREPLACEDRYER ���������'��_ FRYOLATOR --__--�____--�= FURNACE —♦—��-----_— GENERATOR —_____'_—_-�� GRILLE ��-__ --_�___- •ip tINFRARED HEATER ___— ---�— W LABORATORY COCK — 1.111111111111111111111111 —!'-- -- _ OVEKEUP AIR UNIT �_ __��—__ �_ POOL HEATER _ ���_— ROOM/SPACE HEATER 1 —__--���— =_ .l ROOF TOP UNIT �'v'==�=r_—_� ' TEST — —1111111111111--__==— 1 UNIT HEATER ..� UNVENTED ROOM HEATER =___��m— —_—__- WATER HEATER __�__ —___ —___ 11.11_— __ 1 --=--�--�__INSU '� CE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.14 2 If you have checked YES,please indicate the YES 0 NO ❑ type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ID certify that all of the details and information I have submitted(or entered) Knowledge and that all plumbing work and installations performed under the permit issued for this application wille and a m ate to the best of my provision of the Massachusetts State PI„ • Code and Chapter 142 of the General Laws.44 went PLUMBER/GASFITTERNAME: (<G r2 _.LICENSE#Mill SIG TURF COMPANY NAME: ()e2 (Z ;5 ADDRESS: S CITY: STATE ' I/� A ZIP 63 FAX: TEL: CELL: EMAIL: SOS S� `�ct'r 'C GN'l MASTER 0 JOURNEYMAN Xj- LP INSTALLER❑ CORPORATION 0�1 PARTNERSHIP 0 a LLC 0#_______ C 139,-iL ADL12eSS :