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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�1 CITY ✓!! • /li ILIA//� _' MA1DATE/Q-f -/d .PERMIT# 64015-79—(X:472.9%
G4 4'I�e/hb rc i%i4 , ,OWNER'S NAME
JOBSITE ADDRE - I `✓✓
GOWNER ADDRESS _. TEL q S.stylAX .
TYPE OR OCCUPANCY TYPE COMMERCIAL ,,' EDUCATIONAL RESIDENTIAL
PRINT I '
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CLEARLY' NEW:I.:, RENOVATION: _.' REPLACEMENT: ... 1 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 w� ®_
DIRECT VENT HEATER
DRYER ®�®®
FIREPLACE ' NEM
FRYOLATOR
FURNACE MN
GENERATO
GRILLE . .
INFRARED H ATER ®®®
LABORATO- COCKS
MAKEUP AIR UNIT _
OVEN 1
POOL HEAT R MSM® .- .
ROOM/SPA EHEATER 111111111111111111111111111
ROOF TOP UNIT ®®�� _..
TEST I NS
UNIT
UNIT HEATS- MOM
UNVENTED ROOM HEATER 1 - -
WATER HEA ER ®®®®
OTHER ®®®�
_®®® _ .
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INSURANCE COVERAGE _-
I have a CurrRnt liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 12.,NO ,_
I IF YOU CHE¢KED YES,PLEASE INDICATEITHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY +,: OTHER TYPE INDEMNITY BOND j,,_
OWNER'S INSURANCE WAIVER:I am a re that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that p/y signature on this permit application waives this requirement.
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I CHECK ONE O. : OWNER ... AGENT ,..
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Mar-nation I have submitted or entered regarding this application are . e and a. e t of my knowledge
hep application will be in c• pliant= tier,II P�v ion of the
and that all plumbing work and installations Performed under the permit issued for this
Massachusetts State PlumbingCode and Crater ter 142 of the General Laws.
� ... -
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PLUMBER-GASFITTER NAME ANDREA LEIGHTON LICENSE# 16130-M SIGNATURE
MP ! MGf JP JGF , I. GI ` CORPORATION .+,# 3734C 11.PARTNERSHIP ,. # _ __ LLC # �._...
COMPANY IME HALL OIL COMPANY INC f ADDRESS 435 RT 134
CITY S0, TH DENNIS STATE MP,_ ZIP 02660 TEL ..528:?. 13-3831
FAX 508-394-3068 ..CELL , EMAIL hallollcom an mail.com P Y. ! atf
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