HomeMy WebLinkAboutBLDG-17-003930 #A 1I17ASSACHUSt I S S U[ttiFORII;S APPLICATION FOR A PEP1 IT TO PERFORM GAF,Fi :!Ri.G WOR`.
( CITY L _ _ y4/, , v t4.- C I, MA. DATE _ .2 4 /i 7 1 PERMIT t:`:f` -'P er 7/7 oc J V. Gt
JOBSI t E ADDRESS dC7i) Iv,,/y/2i OWNERS NAME j i Cc -r L-',c=
113- OWNER ADDRESS: I`/. / 5_t ✓7`S J` rii sh,4,v,.I11v11, TEL: 1 `f/.7-(;>26" acy--1,FAX:L
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CL E a.^•L Nair,0 RENOVA ION:1 l REPLACEMENT:Lrj''" PLANS SUBMI t I 1-...U: YES[1 MO -
FIXLI T I?ES "I FLOOR 1 ssnt 1 -( 2 I 3 1- 4 5 1 S 1 7 I 8 9 ( 10 i i 1 12 113 1 14
BOILER I ! I ! ( I 4 1 1
BOOSTER 1 - I I - I-
CONVERSION BLIPiNER !� - i - ! 1 I # ( ! 1 F! ! ! ( 1
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INSURANCE COVERAGE
I have a cu,-eni liability insurance policy or its substantial equivalent 1_frith meets the rernimments of ISMGL Ch.142 YES I nID 0
if you have checked YES_please indicate the L3rpe of coverage by checking the appropriate bar,helot_t.
LIABILITY INSURANCE POLICY —mil/ OTHER TYPT IA1DRi~ Ni'Y 0 BOND 0 •
OWNER'S INSURANCE WAIVER:I am aware that the licensee does no have the insurance coverage required by Chapter€42 of the -
Massachusetts Gene aI LaVES,and that my signlature on this permit application waive this requirement _
CHECK ONE ONLY; OWNER LI AGENT 0
SIGNATURE OF OWNER OR AGENT -
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hereby certfy that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the beta;n r
1-(nowiadge and that all plumbing wait and insiallatians performed under the permit issued for this application will be in compliance with all Pertinent
provision of the Massachuset's State Plumbing Code and Chapter 14.2 of the General Laws.
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