HomeMy WebLinkAboutGas Permits gk°:._- MASSACHU SETTS tJNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
:i?I lUt CITY 1 tt r '1s,tc.'C 1 MA DA I E j Lt 1 t// /Oil `PERMIT#(549 1 '''01/7.6
JOBSITE ADDRESS' t -1 NW t,/ �i , }} j' Li,) OWNER'S NAME (1��(6.1()c tr)( , ,
�� OWNER ADDRESS { I(,`i Gi l IY) t: A 1 t� ..eta { i rd�'`k EL FAX I
t YPr O OCCUPA .Y TYPE COMMERCIAL I EDUCATIONAL RESIDENTIAL I,
PRINT
CLEARLY NEW 3._.. RENOVATION:IREPLACEMENT:{ ` PLANS SUBMITTED: YES', ? NO 1'
APPLIANCES 1 FLOORS—' BSM I 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE E..
DIRECT VENT HEATER
DRYER I
FIREPLACE
FRYOLATOR
FURNACE
--
GENERATOR
GRILLE
INFRARED HEATER
~LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
N. ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
\\ 'OTHER
V
INSURANCE COVERAGE
C I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES HH 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
vMassachusetts General Laws,and that my signature on this permit application waives this requirement.
`� —___........__._. CHECK ONE ONLY: OWNER I „ AGENT I I
SIGNATURE OF OWNER OR AGENT
vA I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate pest of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit • e ' v€supn of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER GASFITTER NAMEencer Hallett LICENSE# 18224 IGNA E __—
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MP i MGF j JP 1 i JGF I LPG! CORPORATION I.� # 3834 PARTNERSHIP #1 LLC? it
COMPANY NAME:Spencer Hallett Plumbing and Heating Inc. 1 ADDRESS 381 Old Falmouth Rd Unit 36
CITY Marstons Mills STATE Ma iZIP02648 TEL 508 428 tit)80
FAX 9 CELL! EMAIL spencer(cihallett lumbin9 corn
/W/-/8- co a377
illAOSf CI IUS 9`s S QI IG•OW ALl'LICIV i t$ FOR A PERMIT TO PARR R `1 PLJIWEII K WORK
;at m: CITY G "d'viGJfl t 4 17t/ r`
_��� ._ i L l MA DAT L (1 >' PERMIT#
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JOBSITE ADDRESS r t" l t x`l �' (t� -lei OWNERS NAME[-„ I/jlL{ ( G1► Ci(_1"1Fd 1
OWNER ADDRESS atii'Yi,t '-, J, o� e- - h ( i TELW _ 1
TYPE OR OCCUPA7Y TYPE COMMERCIAL EDUCATIONAL L RESIDENTIAL 1171
PRINT _
CLEARLY NEW:L,�,;; RENOVATION: REPLACEMENT:[ I PLANS SUBMITTED: YES L. NO��
FIXTURES 1 FLOOR-. BSM 1 3 4 5 6 7 a 9 19 11 12 13 14
T
BATHTUB I I r {
CROSS CONNECTION DEVICE i _ . ,I, . I _'
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-_-. -. 1 I I
DEDICATED SPECIAL WASTE SYSTEM - f 1 !� ` '
E
DEDICATED GASIOIL/SAND SYSTEM . _
DEDICATED GREASE SYSTEM [ : . AMC 1 I s" 1. -
DEDICATED GRAY WATER SYSTEM ��
DEDICATED WATER RECYCLE SYSTEM f r j,i 1C_,- 7I _ 1 l f ,i, 1 _
; ,. :
DISHWASHER _.._.. ;I ;—
DRINKING FOUNTAIN ( — .
FOOD DISPOSER —
FLOOR/AREA DRAIN - I— 1' - 1- =_--
INTERCEPTOR INTERIOR i ; —' , _ -__'
KITCHEN SINK .__,____`
LAVATORY [ [ -,,1 4
ROOF DRAIN I.. .. l t s
SHOWER STALL ®; -,'
SERVICE/MOP SINK ( '-.._. I
TOILET I _t
URINAL lattiall ..-.f oi ®r
WASHING MACHINE CONNECTION [ ---
WATER HEATER ALL TYPES '-.----E 1111111111111 ,
WATER PIPING rm I_. -
OTHER Ii 5i -l 5
I--
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Er
NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
' r
LIABILITY INSURANCE POLICY Ir i OTHER TYPE OF INDEMNITY [ BOND L
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 Li AGENT L_
SIGNATURE OF OWNER OR AGENT
—
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accu . e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In compliance all r= in '-pr ' ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,- ,
PLUMBER'S NAME Spencer Hallett_ !LICENSE#I16224 f SIGNA RE
MP[ '; JP[_'t CORPORATION#[[_ �� i PARTNERSHIP ; ,'#E _;LLCM`#L �
COMPANY NAME Spencer Hallett Piumbin and Neat n ,Inc ADDRESS 382 Old Falmouth Rd Unit 36
CITY Marstons Mills =I STATE r Ma ZIP 02848 -_- [ TEL 1508-428-6080
FAX N1. 28 7991 II CELL I I EMAIL pen scar halie lumbin com E
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