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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY [,�,I_ tA., 1:UaLI(S._ 1 MA DATEL4 7 JJ PERMIT#
JOBSITE ADDRESS Lc2.0 OWNER'S NAME
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TYPE OROCCUPANCY TYPE COMMERCIALS EDUCATIONAL 9 RESIDENTIAL.
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CLEARLY NEW: RENOVATION:® REPLACEMENT:❑ PLANS SUBMITTED: YES Q N0
APPLIANCES 1 FLOORS—. 8SM 1 2 3 4 5 6 7 8 9 10 11 - 12 13 14
BOILER ;' I i,
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BOOSTER 1 '( II
CONVERSION BURNER ,
COOK STOVE — —
DIRECT VENT HEATER
DRYER ]di
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FIREPLACE
FRYOLATOR ; ----.
FURNACE 11 t —I _�
GENERATOR i .
GRILLE
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INFRARED HEATER
LABORATORY COCKS <� -
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MAKEUP AIR UNIT
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POOL HEATER
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ROOM I SPACE HEATER c`
ROOF TOP UNIT i ;
TEST i . r. 1 '
UNIT HEATER I _ 1 ....... 1' ' __ _._._,r
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UNVENTED ROOM HEATER i �.
WATER HEATSj� _ _ '
OTHER ��/iYjN 1� NE; au
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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 YEWI ]NO L
IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY Q OTHER TYPE INDEMNITY 9 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 permit application waives this requirement.
CHECK ONE ONLY: OWNER 9 AGENT L7,1
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 a d accurat the b of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be In mp e with mine ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME'WILLIAM H.POOLE (LICENSE#'12879 SIGNATURE
MP 16,;„-j MGF0 JP0,, JGF0 LPGI[0 CORPORATION 0#1.2.338C PARTNERSHIP 0#1— LLC 0#1____11
COMPANY NAME HALL OIL CO.INC. (ADDRESS 435 RT 134 1
CITY •SOUTHDENNIS I STATE MA ZIP[02660 (TEL 150&398-3831
FAX'508-394-3068 (CELL ]EMAIL, bb ga@cape.com
NOV 14 2013 fi
BUILDING DEPARTME?!T I ./
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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