HomeMy WebLinkAboutBLDG-25-237 qoP (ipfikAtinn, R CEIVED
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APR 24 2025
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MASSACHUSETTS UNIFORM PP1 ITION FOR A PERMIT TO PERFORM , EN—
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—ByCITY: MA. DATE: 7
JOBSITE ADDRESS: O (.44OWNERS NAME: 5t7rL 64'
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G OWNER ADDRESS:'9 .i 0 L '' S I1A+Y_ )Q(\ TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT' PLANS SUBMITTED: YES 0 NO'
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
V} INFRARED HEATER _
LABORATORY COCK ,
MAKEUP AIR UNIT _
' OVEN _ _
POOL HEATER
ROOM/SPACE HEATER _
.I ROOF TOP UNIT
' TEST I _ .
:Z UNIT HEATER
I.0 UNVENTED ROOM HEATER _
WATER HEATER _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ] NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 and ccurate to the st f my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be I mp ance al ertinent
provision of the Massachusetts State Plumbing Code and haptell 42 of the General Laws.
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PLUMBER/GASFITT NAME: 1 LICENSE#3/i 7 J SIG URE
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• 3COMPANY AME: a P/041 ° J ADDRESS: r—ZI—- %'""
CITY: STATE:ail_ ZIP: FAX:
TEL: CELL: EMAIL:
MASTER 0 JOURNEYMAN X LP INSTALLER❑ CORPORATION 0# PARTNERSHIP❑# LLC 0#
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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