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HomeMy WebLinkAboutG-14-175 • 4 3 7 i 33 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ''-r °Mw.ww6v1 CITY Lf. � Aigttt f,.jt,.r - MA DATE to 210-AJ PERMIT# C7Iy� �7 JOBSITEADDRESS L-71, ( SDS.-sIOWNER'SNAMEF/L/ CPGC.2/t111I GOWNER ADDRESS 511_ _I TELi3 8 7'// -- jlFAX , J TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL❑ RESIDENTIAL[ PRINT CLEARLY NEW:0 RENOVATION:Q REPLACEMENT:21 PLANS SUBMITTED: YES© NOE3 APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 '1 BOILER vree.z.l ,' vvrn '-xa.vu 1'.w_ . car ,_. ...•,. .w .' 11 ii i, i BOOSTER _ _ CONVERSION BURNER t COOK STOVE ii I 1 DIRECT VENT HEATER DRYER 1 ;l ;i i i, n FIREPLACE ' .. ' - - �.. .: ;i FRYOLATORI i FURNACE ` z GENERATOR INFFtARED HEATER < III . t, ,, ,1 � � 1zI!EE !±IIIIIH IIR UNITitTERy( jACE HE ' --.I?UNITERD ROOMEREATER OTHER I INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 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 LI 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 pemtit application waives this requirement CHECK ONE ONLY: OWNER ® 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 accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in corn iance with all Pertinent rovi ' n of e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p /- /• (AA�ym PLUMBER-GASFITTER NAME'WILLIAM H.POOLE I LICENSE 4.12879 ! VVVIIV// SIGN TURE MP Li MGF[ JP 0 JGF 0 LPG![ CORPORATION 0#I2338C PARTNERSHIP 0# LLC 0#1-----1 COMPANY NAME:HALL OIL CO.INC. 1 ADDRESS 1435 RT 134 CITY !SOUTH DENNIS • —_ . STATE MA ZIP 02631 JTELI508.398-3831 I FAX 508.394.3068 CELL JEMAIL bbq@cape.com ROUGH GAS INSPECTION NOTES THIS PACE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES