HomeMy WebLinkAboutBLDG-15-005431 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
NNW LY pb F� �3/
' tIL CITY ifrilidgial} 1 '27',. IMA DATE 6- q -14 PERMIT#
JOBSITEADDRESS I D CA"Cvwwrr vat„ 1OWNER'S NAME NA.itail
GOWNER ADDRESS SA-ryte ITELJ '3L2-Z5/7.2JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL Ei RESIDENTIAL Ej
PRINT
CLEARLY NEW:Er RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I I �(
._ ..0 I11.dLY3G ddL!A- .:.:LW1L I11 Y.=. 1S_
BOOSTER II I .v II 1( I- 1 3C 1
CONVERSION BURNER I IPS i 11 _, 1 I _ i 1
COOK STOVE 1 1
DIRECT VENT HEATER '1
DRYER
1—
DRYER — 'I " - P I 1 I
FIREPLACE i 1 I
FRYOLATORk '1
FURNACE _`!f —) m i � 'I — _ I
GENERATOR : 1111
GRILLE p a 4 IMINNUONIOSIIIMINICIONIIIIRMICIMMESSIMNICMIS
INFRARED HEATER
1001_-
. 00
LABORATORY COCKS 10
_ _0110 _ - - - _ __
MAKEUP AIR UNITINSCIMOCIMINNOMMIN
OVEN
- -111101111USIMMONSUISIMINIMIKININIMINNIS1001 I
--
POOL HEATER T4_14,11 : '11 i,,,,“..„._ 4_,_ 4)__ I, ii
ROOF TOP UNIT
TEST
UNVENTED ROOM HEATER ' 11
• vWATER HEATER I- l''!!!
_J [ ( f ,.—.,� .e•i,
INSURANCE COVERAGE IIIr1 n r,.._201., 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. h.142 YES '+ O [1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW t: 1 aKi r i iii-I D
a�oY "'JC/
LIABILITY INSURANCE POLICY p OTHER TYPE INDEMNITY ❑ ON ❑
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 ONLY: OWNER ❑ AGENT El
SIGNATURE OF OWNER OR AGENT '
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli nce with allPertent vision I the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER-GASFITTER NAME WILLIAM H.POOLE LICENSE#52131u IGNATURE
MP❑+ MGF❑ JP❑ JGF❑ LPG'❑ CORPORATION Q# 2338C PARTNERSHIP❑# LLC❑#
COMPANY NAME: HALL OIL CO. INC. J ADDRESS 435 RT 134
CITY SOUTH DENNIS I STATE MA ZIP 02660 TEL 508-398-3831
FAX 508-394-3068 CELL EMAIL bbq@cape.com
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY, FII
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES