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.'= JOBSITE E ADDRESS: 7 /'/1 • Gj OV I ltRS NAME it2e11r,a'�' o s4 e'
! I G OWNEP.ADDRESS:_ `5 /it .P • TEL AX:.
TYPE OR OCCUPANCY'TYPE COMMERCLkL❑ EDUCATIONAL ❑ RESIDENTIALerr
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CLEARLY NEW:❑ RENOVATION:❑ REPLACtEENT:( PLANS SUBMITTED: YES❑ N0/141
I APPL1ANCES-! FLOOR I Bsnt 11 1 2 I 3 1 ! I 5 I o 1 7 1 o I 9 I 10 1 11 I 12 I 13 I 14
I BO1LEP. I l I
• I BOOSTER.tR I I I I I I I I I I I ! J
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I CONVERSION BURNER I I I i I I I
COOK STOVE I I 1 I I I I I I
I DIRECT VENT HEATER I I I I I II I I
) DRYER I i 1 I I I I
1 I FIREPLACE I I ! I I I I I I I
1 FRYOLATOR I I I I I I I I
1
FURNACE I I I . I I I I I
GENERATOR
GRIME I i I I I I I I
INFRARED HEATER I I I i I I I I
LABORATORY COCK I I I I I I I 1
I MAKEUP AIR UNIT I I I I I I I I
1 OVEN
I POOL HEAT .iR .I I I I I II
1 ROOM I SPACE HEATER I I I I I .
1 ROOFTOP LIR.7 I I I I I I
I TEST
l I I I I I
I UNIT HEATER I I I I 1
I U 'V2.ITED ROOM HEATER I I I I I I '
I WAitrth'EAT= I I 1 1 1 ` I
1 I I I I I I
I 1 1 1 I 1
1 1 1 I
INSURANCE COVERAGE
I have a currant liabrtity insurance policy Or its subs rrilal equivalent which c-eetc the requirements of NIGL CI-.142 YES ] NO 0
if you have checked YE,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
DINNER'S INSURA}CE 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 ❑
SIGNATURE OF OWNS.OR AGENT
hereby cermy That all of tie details and iniormaaon I have submitted(or entered)regarding this appGcaiion are true and accurate to the best of my I
Knowledge and chat all plumbing work and inssliations performed under tie permit issued for this appliuton will be in Dance with all Prriinent
provision of tie Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
/
PLUIJiBERIGASH I I tRNAli4E,,"'41.4 ,6(Po /3 LICENSE#Ao/27 SIGNATURE
COMPANY 1" JE: ADDRESS:
•
CITY: Dtea('/'/ STATE / e_ ZIP:l�Gj 6 7 FV:
Tam '77a—.5if "�a.L: EMAIL'
MASTER❑ JOURNEY ' L P INST.^ I 7 CORPOP,A.T 1ON ❑ PARTNER-: !P i-I
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