HomeMy WebLinkAboutBLDG-19-004045 y
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 57 hat" Pv.D ,IOWNER'SNAMETim-
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GOWNER ADDRESS 5 � Tag-St-15541 FAX . _ ..}
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL I
PRINT
CLEARLY NEW✓ R NOVATION: REPLACEMENT: ._. PLANS SUBMITTED: YES -,< NO;+,.
APPLIANCES 7 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 GAS t p f
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT • RECEIVEDj ,
OVEN
POOL HEATER
ROOMISPACEHEATER JAN (19 2019
ROOF TOP UNIT {{ I
TEST 1 ,�
UNIT HEATER at'
UNVENTED ROOM HEATER
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WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL Ch.142 YES ft; NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J..' 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 e and a .et• he b:-t of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be Inc. pliant= t1-II P irl - • ovIon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /11111110..—
PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M SIGNATURE
MP % MGF ' JP JG F LPG. CORPORATION !;# 3734C PARTNERSHIP . # LLC #
COMPANY NAME: HALL OIL COMPANY INC. ADDRESS 435 RT 134
CITY SOUTH DENNIS STATE MA ZIP 02660 TEL 508-398-3831
FAX 508.394.3068 CELL .EMAIL hallollcompany@gmall.com
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