HomeMy WebLinkAboutBLDG-17-005066 —z- b ASSAC`t USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK —
CITY Vkaarnov b;sh•a•onov 'poe )MA DATE 3--3\-%-7 PERMIT#A-46 'J7'—O6 OW
• I JOBSITE ADDRESS \'1a, Ce, e �kcz�e.--k* OWNER'S NAME SFawnu8,k P\4r•- (
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� OWNER ADDRESS Same TEL 5 O'6_�yk.,,_O3 5 8 FAX
TYPE OR I
OCCUPANCY TYPE COMMERCIALPRLNT EDUCATIONAL RESIDENTIAL ✓
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NEW: RENOVATION: REPLACEMENT: I PLANS SUBMITTED: YES NO
APPLIANCES FLOORS BSM i 1 2 3 4 1 5 j 6 7 8 9 10 11 12 i 13 14
BOILER 1 I I
BOOSTER IMIIIIIIIIIIIIII j ��
CONVERSION BURNER i I j
' COOK STOVE 1 j _j
DIRECT VENT HEATER _� I i I
DRYERj ji I
FIREPLACE _�_-111111111111 I I j
RYOLATOR i I I — ! I I
FURNACE I 1 I
I GENERATOR ! _
GRILLE _� 1 I I
' INFRARED HEATER M j I ! I _
LABORATORY COCKS —_—__M i
I MAKEUP AIR UNIT I _—
, OVEN 1
I POOL HEATER I j I I j i •
I ROOM/SPACE HEATER iIIIMIIIIIIIIMMINIIIIIIIIIMI I 1
ROOF TOP UNIT I I j I ! i i
1
I TEST
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I UNIT HEATER
I JNVENTED ROOM HEATER j I — I I
I WATER HEATER I I I j I I —
I OTHER l j I I I i
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ' NO
1 i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
I 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
j Massachusetts General Laws,and that my signature on this permit application waives this requirement.
ICHECK 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
I and that all plumbing work and installations performed under the permit issued for this application will be in complianceall Pertinent vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
1 PLUMBER-GASFI T TER NAME Matt Woodward
LICENSE# 30553 SIGNATURE
1 MP MGF JP JGF LPGI CORPORATION
PARTNERSHIP # LLC #
COMPANY NAME: M.Woody's Plumbing and Heating ADDRESS 198 hurston Street
I STATE MA ZIP 02093 TEL 508-838-7862 •
CITY Wrentham
t FAX CELL EMAIL mwoody8905@gmaii.com a#
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