HomeMy WebLinkAboutBLDG-25-236 RECEIVED
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APR 2 �025
« MASSACHUSETTS UNIFOR APPLICATION FORA PERMIT •gutUmiNIRK
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CITY: P� (rf t"�C>L ^/ MA. DATE:t i :^ /HERMIT# DG
JOBSITE ADDRESS: e2 5-- fl1►l'b c�(p ; OWNER'S NAME: /y 1/ rrf F'
GOWNER ADDRESS: 5 G,Z''-€i TEL: FAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:15K PLANS SUBMITTED: YES❑ NO TX
APPLIANCES1 FLOOR-0 Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
Iv} INFRARED HEATER _
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
,-4 POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
fi TEST •
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER J
•
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESX NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 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.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true a accurate to e best of my
Knowledge and that all plumbing work and installations performed u der the permit issued for this application will corn lia all Pertinent
provision of the Massachusetts State.Plumbing Code and C pter 2 of the General Laws.
PLUMBER/GASFITTE NAME: U LICENSE#air NATURE
COMPANY N E: '' DRESS:
CITY: Pqr LAp, r lr- STATE: //),..4 ZIP: FAX:
TEL: CELL: O j7t!57V3 EMAIL:
MASTER❑ JOURNEYMAN LP INSTALLER❑ CORPORATION❑# PARTNERSHIP Cl# tic❑
E h? AD7.12e-SS Gila��il �jSl�� l )':<ia1/<<7i'f
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES