HomeMy WebLinkAboutBLDG-15-001132I G
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CITY: /G�" Vy� :� . �/ MA. DATE: PERMIT r&il 7/5 t0// `�
JOBSITE ADDRESS: 2 �o G- CIIA ST'� OWNER'S NAME � �� u ✓ o'� YGs'w.ci�`
OWNER ADDRESS: ��1- Ho1, T EL' FAQ
OCCUPANCY T YPE COWi1JERCV L [f EDUCATIONAL ❑ RESIDE14-11AL ❑
IqEYV: ❑ RENOVATION: ❑ REPLACEIk4ENT: [[� PLANS smv I( i ED: YES ❑ NO
I APPLIANCES'
FLOOR—
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I DONVERSION BURNER
COOK STOVE
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DIRECT VENT HEATER
DRYER
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FIREPLACE I
FRYOLATOR I
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GENERATOR I
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!! ABORATORY COCK
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MAKEUP AIR UNIT
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1 -1 EST
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INSURANCE COVERAGE
I have a current EaOtLinsurance policy or ins substantial equnralentwhich meets the requirements of NiGL CIL 142 YES �0 ❑
tr you have checked Y=� please indicate the type of coverage by checking the appropriate box below_
LLKS11- Ty INSURANCE POLICY [� OTHER T YPE INDEMNR Y ❑ BOND ❑
OWNER'S INSURARCE WAIVER 1 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 ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby ceriiry that all of the details and information I have subrri ded (Dr entered) regarding this appkaiion are true and accurate tote best of my I
Knowledge and that ali plumbing work and installations pariormed under the permit issued for this appricaiion vAll be ' compWance wish all nern
provision of the Massachusetis State Plumbing Code and Chap/ter 142 of the Genera! Laws.
PLUMBBJC-ASI I NAh4E -.- G�e,, LICENSE# SIG NATURE
COMPANY NAM)= ADDRESS: 2.G �� -� o-- s ��o l I� Ck
CITY : � {' C,� , L `-- STATE: ZIP: '� Z 6 FAX
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MASTER ❑
G EMNL:
JOURNEYMAN L P INST' ❑ CORPO,RATION ❑
oli 0 GAS TUNW9021CTION
1.118 y/kGg FOR JINSPEC'I'O71 ]JUe ONLX
Yos No
TI-IIS APPLIOATION SLRVES AS TI IE PE.IZMIT ❑
FEE: $_ PERMIT #
PLAN 111,7V11C11' NO'1'Ia�J
FINAL INSVECI'ION N0110
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