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I MAC AL:HU:'GiTS UNjEUK10A- Lit-A1iv IN rune rL.-rur,,, .,..+ . ,-... -..... _. .- . .. ._-.- .__.-'_ '--
jFi CITY MA_ DATE:? a.�i PE-'arr/ +Ob•/�O5.$
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JOESI i E ADDRESS: - /l e-V 0 JNER S NAME
I G OWNER ADDRESS: S - ' T B. 'FAX:
of TEE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDB IAL r
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c',� 1 I CLr- �' NEW:❑ RENO\/Ai ION:sr REPLACEE�/iEN :❑ PLANS SUBlvi 1 1 : YES❑ NO R
"jA I APPLIANCES, FLOOR-. I Bsnt 1 I 2 3 1 4 15 1 5 1 7 8 I 9 10 111 12 I 13 I 14
IBOILER. 1 1
BOOSTER I I I I I I l l I I I ;
I CONVERSION BURNER I I 1 I I I I I II
I
COOK STOVE I I I I I I I I I
I DIRECT VENT HEATER I i I I I I I I II
J DRYER , I I I I I I I
I FIREPLACE I I I I I I
FRYOLATOR ; I i I I II I
FURNACE I I I I . I • I I I I
I GENERATOR I I I I I I I I
I GRILLE
INFRARED HEATER
; LABORATORY COCK
MAKEUP AIR UNIT-
! o I I I I I I I I
I POOL HEAT .r I I -I I I I I I I
ROOM 1 SPACE HEATER I I I I I I I I I i .
I ROOFTOP UNITt I I I I I I I I
1 I,�... ���� 0 i I I I I I I I I I
I I I ! I I 1 I
Ul\% i T ROOM}—EAj N I I I I 1 1 1 1 I 1 1
WA 1T 1-EAT fie'''.
I I I I I I I I ' I I
W I I I I I I I I I I I
�'Stl 1 I 1 I 1 1 1 I 1
,/ARTMENT I 1 1 1
,r '! INSURANCE COVERAGE
I have a currerrt Uabi ity Insurance policy or its s-ubstntial equivalent which rnetc The requiremer of N GL Cli.1".2 1 t`'-S. k] NO ❑
If you have checked YES,please indicate the type of coverage by checking the apprapriay box below.
LABILITY INSURANCE POLICY 1. OTHER-TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER I am aware Lai the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this perrnitapp1icaaon waives this requirement
CHECK ONE ONLY: OWNER❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of The details and information I have subrrirlied(or entered)regarding this appGcauon are true and accurate tote best of my 1
Knowledge and that all plumbing work and inssllations performed underthe penmrl issued for this application will be. fiance with all Pernnent
provision of The Massachusetts Stare Plumbing Code and Chapter 42 of the General Laws.
PLUMBERIGASH i I tKNAME: /1 -,'l4 ,/1GZ—//` S LICENSE#R267/7 7 SIGNATURE
COMPANY NAME: ADDRESS: e_--
CITY:S i�1�e/ STATE 11,4 ?1P:O r AX:
TEL <9.$'71° .5VPc CELL: EVAIL:I i e Alt C 10 0 .il0 1z,_
MASTER 0 JOURNFAILAN FA LP INSTAWER 7 CORPORATION 0 PARTI c-IIP❑i-. lac
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°UGH GAS i SPEC' .10 OT ; ' �.'naPAO!,FOR JIY�S,I'EC:TOR U,SI;'ONLYl�l`li1 L 1N,S�'L�
/4.Ro7 0. g 7 r/,- Yos No
THIS APPLICATION SERVES AS THE PERMIT ❑ D -------
FEE: 1_ PERMIT If -
I',LAN J.INVIJE}1'NU'i'A;Y .__-