HomeMy WebLinkAboutBLDG-15-003235 •
.' - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
YLi CITY W . O A R 71 O 1,0-11- MA DATE PERMIT#Bt'1 ,--15.7.0 S
JOBSITE ADDRESS 19 62Et"sm e P8)40 'OWNER'S NAME poll ✓OC2t•c3z% 9
G OWNER ADDRESS S Asset C. I TEL 4,8,7 76,4.7 cif (FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL El RESIDENTIAL 0
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CLEARLY NEW: j RENOVATION:0 REPLACEMENT:Q PLANS SUBMITTED: YES 0 NO0
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 tli 6 9 10 11 12 13 14
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INSURANCE COVERAGE
I have a current Jiabilitv Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142IN. IC YES ONO E III
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW F' EY
LIABILITY INSURANCE POUCY 0 OTHER TYPE INDEMNITY Q BOIL la DEC 02 201
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chppt4 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement. BUILDINGDEPARTME T
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CHECK 0 E 0 b OWNER Q AGENT IN
SIGNATURE OF OWNER OR AGENT i
I hereby certify that all of the details and information I have submitted or entered regarding this app -C. ar-'true • accu - - • e best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this applicatio 'll •- ink.mpli i,-with :11 Pertinen provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. is
PLUMBER•GASFITTERNAME Andrew Leighton (LICENSE#m 130-M SIGNATURE
MP 0 MGF Q JP Q JGF Q LPG!Q CORPORATION 0# 2338C PARTNERSHIP Q# I LLC Q#
COMPANY NAME:Hail Oil Co.,Inc I ADDRESS 435 Route 134
CITY South Dennis ( STATE MA ZIP 02660 TEL 508-398-3831
FAX 508-394-3068 CELL EMAIL HALLOILCO@YAHOO.COM '