HomeMy WebLinkAboutBLDG-17-003907 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `
3 '' CITY LS0,furnov- Cv,)_., `�f:krimou )MA DATE \-' .S-17 PERMIT# /fir?`/7190g/OY
JOBSITE ADDRESS \glp Foaccv �c>,d OWNER'S NAME SllaeN 4Ae.S.v.Nc1
OWNER ADDRESS Same TEL 50%.a,.,t6-eyla.t FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL V.
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: 1 PLANS SUBMITTED: YES NO Ne
APPLIANCES = FLOORS— I BSM _ 1 2 3 4 I 5 1 6 7 8 1 9 110 1 11 I 12 1 13 i 14
BOILER I I I I I I
BOOSTER 1 I 1 I I
CONVERSION BURNER I I f I ! I
I I
COOK STOVE ( i I
I
DIRECT VENT HEATER I ! r
J
I
DRYER I _
FIREPLACE I 1 1 i I i I 1 I —1
RYO!LATOR I I ! i I I I ! I i
i FURNACE I i I I 4I
i GENERATOR I I
GRILLE _ i I I `
INFRARED HEATER 1 ( I f {
LABORATORY COCKS I ( - 1
r
MAKEUP AIR UNIT I I I I I
OVEN I i I
POOL HEATER I I I r I
ROM/SPACE HEATER _ I ROOF TOP UNIT _
_ f
TEST I I
UNIT HEATER _ ( T
UNVENTED ROOM HEATER _ _
( WATER HEATER I I
( I
OTHER
Hir
I i
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 CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i 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.
CHECK ONE ONLY: OWNER AGENT
SIGNATURE OF OWNER OR AGENT
hereby certify that at of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' /
PLUMBER-GASFITTER NAME Matt Woodward LICENSE# 30553 SIGNATURE
1
I MP MGF JP i JGF LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME: M.Woody's Plumbing and Heating ADDRESS 198 Thurston Street
I
I CITY Wrentham STATE MA ZIP 02093 TEL 508-838-7862
FAX CELL EMAIL mwoody8905@gmail.com
ipti-