22B-015 (4) r�rc�
-
CITY V11Q1'41JC-? MMA DATE (r �' S' PERMIr# l5- ' 30
JOSSITE ADDRESS 5 -re Mel+g(aAl 5r OWNER'S NAME At>6�JP,/J S
GOWNERADDRESS TEL FAX
TYPE OR
PRINT OCCUPANCYTYPE COMMERCIAL[IEDUCATIONAL [IRESIDENTIALLA
CLEARLY NEW:❑ RENOVATIONX REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 8 7 B 9 1 10 1 11 12 1 13 1 14
BOILER
BOOSTER
CONVERSION BURNER it V
COOK STOVE
DIRECT VENT HEATER
164
Fl E
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HE
LABORATORYCOCKS
MAKEUP AIR UNIT
OVEN
POOLHEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECIGNG THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 4 OTHER TYPE INDEMNITY ❑ BOND ❑
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.
CHECKONEONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify But all o1Ba details and information I have submitted w entered regarding this applica8on are true and aowrate W Ba eat of my knowledge
and that all Plumbing work end inetalations perlormed under me permit issued for this application w11 be in compkia with I Penine provisiq of the
MassachuseBs State Plumbing Cale/and Cw
Chapter 142 of the General Las.
PLUMBER-GASFITTER NAME a4c 1�rlgq LICENSE# 110y SIGNATURE
MP MGF❑ J/P{P JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP[I n A LLC❑#
.. C�MpANYNAMF ( ,INd.F I.,nf� 11,A&C
l.1lY ''-�p�7R-�LsaTT STATE7l�NyJ ZIP OlVd � -_- TEL
FAX
FAX CE'LL Sao --73J- 7/ EMAIL
22 I� C!
G`zlf
9,4