Loading...
HomeMy WebLinkAboutG-14-537 N W p /U�-f�Ga4&i" •f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • M 1 ":VALs 1 CITY __5,p xj.E AgM MA DATE I L-t- I51 PERMIT#, i 1 ` 53/ —v r-. JOBSITE ADDRESS nc'jwF,_ij I OWNER'S NAME r(3 I .Lissaata- G OWNERADDRESS F-- 5-AAAF ITELF08, ,60DAX i TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:a RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES© NOD APPLIANCES1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER i E ; I� _ �'. � cam M. - CONVERSION BURNER ., • d_�rl !' va. M l f. COOK STOVE DIRECT VENT HEATER - 41 li , DRYER FIREPLACE FRYOLATOR I `i FURNACE P 1 GENERATOR GRILLE < I '� INFRARED HEATER �.-- I. LABORATORY COCKS I. 'iJwhL MAKEUP AIR UNIT OVEN I i POOL HEATER ROOM/SPACE HEATER p1 II {i i �.. ,_ ....r_ ROOF TOP UNIT 1 TEST UNIT HEATER i A' 'i UNVENTED ROOM HEATER . 11 , iI - l WATER HEATER ,_ 4 .. OTHER , 666 lanaa - INSURANCE COVERAGE d' l I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.C 42 FQI'ES 0 NO [I I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND C# OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of th Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT Ej 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 comp!�'pnue with all Pertinet pro/JJ' ion of the 6' , Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /_ /- 112714 PLUMBER-GASFITTER NAME WILLIAM H.POOLE I LICENSE# 12879 (�{ SIGNATURE MP Ej MGF❑ JP® JGF U LPG!U CORPORATION 0# 2338C PARTNERSHIPL .0j I LLC 0#FT -I COMPANY NAME:HALL OIL CO.INC. _I ADDRESS 435 RT 134 I CITY SOUTH DENNIS I STATE MA ZIP 02660 ITEL 508.398.3831 FAX":508-394.3068 I CELL EMAIL bbq@cape.com RE C E 1 V F D I . DEC 02 2013 iib /. B L -LrG'ARTMe • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY - FINAL INSPECTION NOTES plod 64s'orYes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# PLAN REVIEW NOTES .� i r.