HomeMy WebLinkAboutBLDG-17-004672 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 30 'p, __ St2*ee OWNER'S NAME '-vrZo1/4cy ovsq`.tle
GOWNER ADDRESS Same TEL50 %\. - ta,% FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ✓
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CLEARLY NEW: RENOVATION: REPLACEMENT: I PLANS SUBMITTED: YES NO .rf
APPLIANCES-1 FLOORS-. BSM 1 I 2 3 - 4 5 j 6 7 8 I 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
IFURNACE L I ( !
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER i
ROOM/SPACE HEATER } L_
ROOF TOP UNIT
TEST
UNIT HEATER
L 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 1 NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 all 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
MP MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME: M.Woolly's Plumbing and Heating ADDRESS 198 Thurston Sweet
CITY Wrentham STATE MA ZIP 02093 TEL 508-838-7862
FAX CELL EMAIL mwoody8905@gmail.c:om
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