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1, MASSACHUSETTS UNIFORM, APPLICATION FOR A PERMIT TO PERFORMIGAS
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TING WORK CITY . S.. �(�trl'�+t(fl�lifil MA DATE/Z —/9 �K PERMIT# / Y '17' 5�2i
JOBSITEADDRESS 7.-"A 19 9JJ 1 OWNERS NAME rZie-e.-144/1,4 Ce0
GOWNER ADDRESS , S/4-14 . . TELCOS- 1/657FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL +
PRINT /
CLEARLY NEW:✓ RENOVATION: REPLACEMENT: . 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 ;
DIRECT VENT HEATER
DRYER •
FIREPLACE • •
FRYOLATOR
FURNACE . . . _.. .
GENERATOR
GRILLE . . .. -
INFRARED HEATER
LABORATORY COCKS ...
MAKEUP AIR UNIT •
OVEN _ ....
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER ` ^
UNVENTED ROOM HEATER •
WATER HEATER .
OTHER _ ._ .._
_. .
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES ;t 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 ;
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 AGENT .
SIGNATURE OF OWNER OR AGENT
-I hereby certify that all of the details and information I have submitted or entered regarding this application are . a and ..• jet• _ •=-t of my knowledge
and that all plumbing work and installations performed under the permit issued for this applipation will be in • plia •• /A Il P ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. gir
PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M r SIGNATURE
MP ' MGF JP JGF LPGI CORPORATION +. # 3734C • , PARTNERSHIP # LLC # .
COMPANY NAME: HALL OIL COMPANY,INC. ADDRESS 435 RT 134 _._
CITY SOUTH DENNIS . 1C, STATE MA ZIP 02660 TE 8-398L83 I V
FAX 508-394.3068 CELL EMAIL halloilcompany@gmail.com 33o[! CC/'
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