HomeMy WebLinkAboutBLDG-17-005850 .ti_ I -
., ASSACH SETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK C
CITY l{RQ..'Mc..A)...Cv.1ke_—QN- 'v1A DATE 5- 5 -1-7 PERMIT Aiy-pb-/7-c0
JOBSITE ADDRESS y 3 Pa. ati P,. ,
OWNERS NAME Mora%LyJ+.... m.)R.c.+.-
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OWNER ADDRESS Same
TEL SUtt. 1,,4c5-3S ) FAX
TYPE OR :
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ✓
L Eg?Zt Y NEW: RENOVATION: REPLACEMENT: ✓ PLANS SUBMITTED: YES NO -..'•
APPLIANCES T. FLOORS ! BsM ` 1 12 3 ! 4 5 a ! - I 8 9 j 10 , 1 12 13
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EOGSTER ] ! I i ! I I j T—
CONVERSION BURNER I ! j F j
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DIRECT VENT -EATER + ' ---
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GENERATOR I f i j i ! j
GRILLE ! I I ! i I I I
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INFRARED HEATER I I I ! ; I I ! !
LABORATORY COCKS t I I j l j
MAKEUP AIR UNIT I I I I j
I POOL HEATER
1 ROOM i SPACE HEATER
ROOF TOPUNITi I
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JNVENTED ROOM HEATER I !
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INSURANCE COVERAGE
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 ' OTHER TYPE INDEMNITY BOND
I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
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I 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 re-pardine This application are true and accurate to the best of my knowiedoe
I a-d that at oium'oina work and installations performed under the permit issued for this application v✓ill be in compliance with all Pertinent vision of the
! Massachuseds State Plumbing Code and Chapter 142 of the General Laws. •,�� -'may /
I PLUMBER-GASFI T T!ER NAME Matt Woodward LICENSE A 30553 SIGNATURE
I
I MP MGF JP JGF LPGI CORPORATION A PARTNERSHIP LLC A
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COMPANY NAME: M.Woody's Plumbing and Heating ADDRESS 198 Thurston Street
r:ITY Wrentham
STATE MA ZIP 02093 TEL 508-838-7862
I FA; CELL EMAIL mwoody8905@gmaii.com