HomeMy WebLinkAboutBLDG-19-001829 _.1: ,,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK S
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E1= CITY 5: 3401V:tiRM •- MA DATE?-V'1t• PERMIT# ilD/ 19\-60 U,9
JOBSITEADDRESS ,"T9-9- WjLLptH ,Cr IOWNER'S NAME EAWMOSh1+Tk_. __, j
GOWNER ADDRESS CA-MC .T??7 ! -5555 FAX .. ._
TYPE OR OCCUPANCY TYPE COMMERCIAL , EDUCATIONAL ' RESIDENTIAL +j
PRINT
CLEARLY .
NEW: - RENOVATION: REPLA CEMENT/ PLANS SUBMITTED: YES .; NO',/,:
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER / _ -_
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 ISPACE HEATERi
ROOF TOP UNIT
TEST `- I :-•I
UNIT HEATER SE 2O'LOJ3
UNVENTED ROOM HEATER f
WATER HEATERI _BUl_UIN UEPAgj'j�c"jvz
OTHER ., i; —= —
INSURANCE COVERAGE
I have a current Ilablllty_insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES [2.:-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 j ._: •
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.
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CHECK ONE 0. : 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 a and a. /te t• he b:.t of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in.• pliant= J II P•rti -" w fon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /M
PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M, r SIGNATURE
MP ! ' MGF ...1 - JP JGF ,". LPGI,,,,,I CORPORATION +,# 3734C .:PARTNERSHIP._,. ' LLC _„# „__-_ J
COMPANY NAME: HALL OIL COMPANY INC.... _._....._._..._...._ ADDRESS 435 RT 134 . ., .... .., __- ...__...._....._._._.._,...._ _.-__...1
CITY SOUTH DENNIS----. M._ - STATE i_MA_ ZIP 02660, " _ - .;TEL 508-398.3831_". -_ _
FAX 508-394-3068 ;CELL EMAIL halloilcompany@gmaii.wm
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