HomeMy WebLinkAboutG-19-1962 __. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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k(v` CITY -.,- AiM�a� k/ 1 MA DATE � -J4„_. YPERMIT#0-4)(7-1?-60 Ma
JOBSITEADDRE G _ Q4'1134/.6,411OWNERSNAME K "� g_ l 1‘,„ I, 1
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OWNER ADDRESS V (moi 'TWL!a_.41 = ../ _...__.I
TYPE OR OCCUPANCY TYPE COMMERCIAL.1 EDUCATIONAL ,_ RESIDENTIAL LI
PRINT
CLEARLY NEW:,_1 RENOVATION:Li REPLACEMENT PLANS SUBMITTED: YES,.__ NO 1.,,
APPLIANCES'I FLOORS-” BSM 1 2 3 4 6 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER r
- - a
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER _ :
FIREPLACE
FRYOLATOR _
FURNACE r
GENERATOR ".
GRILLE
INFRARED HEATER
LABORATORY COCKS ,. -
MAKEUP AIR UNIT
OVEN
POOL HEATER Mit 1 . - `
ROOM I SPACE HEATER e
ROOF TOP UNIT _
TEST
UNIT HEATER
UNVENTED ROOM HEATER _..l vLri :,7N
OTHER .
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES L+'NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY :.1 OTHER TYPE INDEMNITY _. BOND L.,'.
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 0 ; OWNER L' AGENT C: .'
• SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are to and■c a • -t of my knowledge
and that all plumbing work end Installations performed under the permit issued for this application will be In Allen waif 11 P-- ,TrT e* Ion of the
. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /orair
PLUMBER-GASFITTER NAME ANDREW LEIGHTON I LICENSE# 15-130-hil SIGNATURE
MP !.i MGF__.! JP y _:' JGF_ LPG' CORPORATION + # 3734C `PARTNERSHIP # LLC '#
COMPANY NAME?HALL OIL COMPANY INC ADDRESS 435 RT 134
CITY SOUTH DENNIS STATE MA .'ZIP 02660 • ._ •STEL 508 398-3831. .
FAX-5084-394-3- 06-8 CELL
EMAIL`halloilcompanA9malicom_...__.,�.. ,. •. .- -. _.,..._. . ....... . ... . '
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