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HomeMy WebLinkAboutG-14-711 •-y. • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V.11-7„,F: +kL I MA DATE /--24—/ PERMIT# 6/0_ 71/ CITY r . TQ �'_1 JOBSITE ADDRESS >.1.2fASAV41D ,oar , 'OWNER'S NAME D_ i s GCj,.S,a GOWNER ADDRESS F C Ft1 QWj 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[ ED C IIONAL0 RES IDE VTIAL[] PRINT CLEARLY NEW:© RENOVATION:DI REPLACEMENT:C1 JAN 21 2014 PLANS SUBMITTED: YES© NO0 APPLIANCES 1 FLOORS-, BSM 1 2 3 4 BSI IJI BIG Oil-A 2Tika .T9 10 11 12 13 14 BOILER , ,. —`--- e BOOSTERId CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE w FRYOLATOR _. i FURNACE _ GENERATOR ,. GRILLE ;:a .�:». e:b..w .tu•e,, x• , *rr,.w: ,.. a„ . .. : a INFRARED HEATER i:: iI _ �i' LABORATORY COCKS MAKEUP AIR UNIT OVEN -.i i_i .r �_.: . i..x »3 .> _._ ..w _ .._ ...a POOL HEATER .taa, +._.. ROOM I SPACE HEATER .__` . r ROOF TOP UNIT I” r,_ `..._ 11 mm' r _ m. TEST _:..,.c. r ;:_x.. r° 'rL. , :a.r r. •,.:.,.. UNIT HEATER � , .. - .. 1 UNVENTED ROOM HEATER i n._ I i WATER HEATER OTHER w1111111111A ,MI' 111111111111.1aNitra 1 • ,mitit an INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES [D NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ED OTHER TYPE INDEMNITY ® BOND 0 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 Q 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 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 complia with all Pertinent ovi n oft e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME WILLIAM H.POOLE LICENSE# 12879 SIGNATURE MP[,�+ MGF[i JP[j JGF 0 LPGI Q CORPORATION EJ# 2338C 1 PARTNERSHIP 0# LLC Lj# COMPANY NAME: HALL OIL CO.INC ADDRESS 435 RT 134 CITY [SOUTH DENNIS w �'1 STATE MA 21P 02660— TEL 508-398-3831 FAX L508-394-3068 J CELL (EMAIL[bbqecape.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL.INSPECTION NOTES Rh*. 645 O, G/2/f i/aJiv Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES t