HomeMy WebLinkAboutBLDG-16-006869 • ._—_ I mAssAcIH.uSETi S UNIFORM APPLICAi IuN rurc A rcrJvii1 I v rcr rv,... „ ,......
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rc,f1): a,= CI1': w , Gl'(`�!lU Mk DATE: 6777/4 PERIJIrt / -/�YT f�0 `MAO
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I ��o JDE51 i t ADDRESS: OWNERS NAME l /'I Eqei,
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f j � G OWNER AADDRESS- - 8 FAti
TYPE Ot OCCUPANCY TYPE COMMERCLkL❑
P EDUCATIONAL ❑ RESIDENTIAL[ }�
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CL d Z '� REND\/f1T101J ❑ REPLACEME T:2� PLANS SUBMI I i J: YES❑ NO I-
1 APPLIANCES. FLOOR-* 1 Bsrt 1 I773072
I 3 I ! j 5 I o" 1 7 1 8 9 10 111 I 12 I i3 1 14
I BOILED. 1 I 1 1 I I I I I 1
BOOSTER 1 1 1 1 1 I I I 1 I !
I CONVERSION BURNER 1 1 ! I I I I I I
COOK STOVE 1 �I 1 I I I I --� ! I I
DIRECT VENT HEATER ! i I I I I I f 1
DRYER 1 I I I I I /(� .� I I
FIREPLACE 1 I I I I I I i I I _
FRYOL4 T OR I ! I ! I I I(16)1 'FURNACE I I I I I . I I I 1
GENEr.ATORI GRILLE Ir IINFRARED HEAT I I I I II LABORATORY COCK ! I I
I MiA►EUP AIR UNIT I
I OVB1 I I I I I
FDOL I-EA CR I I •1 I I I I
ROOM J SPACE HEkTER I I I I I I I I •
ROOF TOP UNIT I I I I L I I
TEST I I I I I I I
UNIT HEATER I I I 1 I I I
UNVa i D ROOM HEA:TIER I I I I I I I I
I WA,T I-EA I I I I I I I
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I I I I I 1 I I I
INSURANCE COVERAGE /
I have a currarrt Ilan-TN insurance.po6 y or its subs,.antial equivalent vlhich rneetste requirernent of NIGL Ch.'1"_2 YES [P'NO ❑
tfyou have chr k d YES ple�.se Mice—Leta type of coverage by checking the appropriate box below.
LABILITY INSURANCE POLICY t OTHER TYPE ULDEANITY ❑ BOND 0
OWNER'S INSURANCE WAVER:I am aware that the Iimnsee does not have the insurance coverage required by Chapter 14-2 of the
Massachusets General Laws,and that my signatlre on this permit appkaton waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby barmy that all of the details and information 1 have submitted(or entered)regarding this appllcauon are true and accurate to ire best of my 1
Knowledge and tat all plumbing work and instillations performed under the permit issued for this applimtion will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n -
PLUtJSERIGAS, I NAh4E �� V- a- _ --`
-� 797/1 ./ 4 q 6)C LICENSE#/7�p,/ SIGNATURE
COMPANY NAME:/4/ f/ V ADDRESS:
Cl T Y: 5Q . riY)p STATE ZIP: /���// y FAX
TEL: 17y- Mid L:-7j71. CELL: EMAIL v �`�/
l,/,s TER❑ JOURNEYRAN L P 11\1ST-141ER❑I CORPORATION E f PARTNERSH!P7
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