HomeMy WebLinkAboutBLDG-16-002564 IMASS ACI-IUSETI S UNiFORMi APPLK:AI ION rum rmr.ivii I 1 L., rcnrv,.,�, , .. ,....r r.� .,
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CITY: y.A .444a C MA DATE /!i:27 VI- P�.I✓rr u //-Db-n,-,'o 6 y
7,', JOESI E ADDRESS'56 ALG/4if7 X,i ..4 ,1'73=4 OWNER'S NAME &.../G/VE''7-
1 OWNER ADDRESS: ae4/ TEL FM:
TYPE OR OCCUPAIJCYTYPE COMMERCLAL❑ EDUCATIONAL ❑ RESIDENTIAL[3—
P1
CL R NEW ❑ RENOVAi 101�:❑ REPLACtI ENT: PLANS SUBMI1 I b.U: YES❑ NO4Q-
1 APPLIANCES1, FLOOR-+ 1 Ssmt 1 1 2 3 1 4 5 1 6 1 7 8 9 1 10 1 11 112 I 13 I 14
1 BOILER I 1 I I I I I I I
1 BOOSTER 1 1 1 II I I I I I
I CONVERSION BURNER, I I
COOK STOVE
I
DIRECT VENT HEATER I I I I I I I I
DRYER I , I I I I I
FIREPLACE I I I I I I I I
FRYOLATOR 1 ; I 1 I I I I I I
FURNACE I i I I I I I I
ER I
j GENERATOR I I I I I I I I
I GRILLE I i I11 ! I I I I I I
INFRARED HEATER I I I II I I I I I I
1 LABORATORY COCK I ! I I
1 MAICiJP AID.UNIT I 1I I I I I I I
POOL HATER j • I I I I I I j
ROOM I SPACE HEATED, I I I I ( 1 I I
ROOF TOP UNIT 1 I I I I I_ I I
TEST 1 I I I I I I
UNIT HEATER I f I I I I I
UNl E t ROOM BEATER I I 1
I WATT .HE Tub I f I I I I ' I I
1 I 1 1 1 1 1
1 1 1 1 1 1 1
INSURANCE COVERAGE
I have a current r_birm insurance ppncy or Ira substaial equivalent which m the requirements of NIGL Ch.142 YES cn1tUO 0
. If you have checked YES,pl��indicate the type of coverage by checking the appropri box below.
LUABDLIiY INSURANCE POLICYg]- OTHER TYPE IMDEMI ►Y 0 BOND 0
OWNER'S INSURANCE CE WAIVER:I am aware that the I'icensee does not have the insurance coverage required by Chapter 142 of the
l riassachusetts General Laws,and that my signature on this permit appkedon waives this requirement
CHECK ONE ONLY: OWNER D AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby certrry that all of the details and iniormalon I have subrrritied(or entered)regarding his appGcahon are true and accurate tote best of my 1
Knowledge and that all plumbing work and ins311aiions performed under to permit issued for this applicalion will be -.Implance with all Pertinent
provision of the Wiassachusets State Plumbing Code and Chapter 142 cite General Laws. 7 ,2/
PLUP,BERIGAS� I NA1\hE/Z( /( /', LICENSE# //2' s' �//i`/Jj "
SIGNATURES
COMPANY NAME: /44)/L77Z r "��� ADDRESS: 7 PznV1 / " /( `/i
CITY: / ' /C// STATE //// - ZIP: ag-6 YS FAX:
TEL: CELL: S?a,--,2-32.2-S7'7 OJiML:
MASTER D JOURNEYMAN❑ LP INSTAIIER❑ CORPORATION C ii t PARTI, SH P❑1= 1
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I OCT 27 201b
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