HomeMy WebLinkAboutBLDG-18-003839 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY SO ( rk MA DATE/L-2 7- /7 PERMIT# A- / —o'l g'J7
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G JOBSITE ADDRESS 2-I L CAM-Q /?L(Y( OWNER'S NAME J`l 1 0 LA
OWNER ADDRESS c tii�� TE/ 3,— "Z) —1-20 7FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW: RENOVATION: REPLACEMENT/ PLANS SUBMITTED: YES NO
APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER a01%6
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST I
UNIT HEATER
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 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 0 Y: OWNER AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are e and a« idte t•the b:-t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c• plianc= t` II P•rt�v ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M SIGNATURE
MP ' MGF JP JGF LPGI CORPORATION # 3734C PARTNERSHIP # LLC #
COMPANY NAME: HALL OIL COMPANY INC. ADDRESS 435 RT 134
CITY SOUTH DENNIS STATE MA ZIP 02660 TEL 508-398-3831
FAX 508-394-3068 CELL EMAIL halloilcompany@gmail.com
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