HomeMy WebLinkAboutBLDG-23-9331 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,c--rings'
44 Y CITY ; 10• 0•3-\\CN � w� 01� PERMIT#MA DATE, __ _� QL O� 23— 3 3(
=
JOBSITE ADDRESS; S Vie; i - --
�� � OWNER'S NAME ��e ,e �cC0.c�� - __
G OWNER ADDRESS S0.rvNQ '.o
TEU 5 �:- e SG� ....FAXl-_-__- __
TYPE OR OCCUPANCY TYPE COMMERCIAL i
PRINT EDUCATIONAL:V RESIDENTIAL
CLEARLY NEW: h RENOVATION:' REPLACEMENT:- ---
PLANS SUBMITTED: YES I-- K.
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 w ;---
DRYER
FIREPLACE
FRYOLATOR .n ..
FURNACE _ -
GENERATOR
GRILLE :a:_ j
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT =
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST V \\N 1
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 I ;NO '
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I 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 ONLY: 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 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 compliance with all Pertine on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME David W.Roderick Jr. LICENSE#967 SIGNATURE
MP MGF' JP JGF+ LPG! 3 CORPORATION 1 #i, .._" ,PARTNERSHIP #; LLC' #.
COMPANY NAME:ICape Cod Oil&Propane - I ADDRESS PO Box 993
CITY ,Provincetown ---___--
____-.- __._.- --_-.
STATE Ilk ZIP 02657 ITEL t508-487-0205
FAX;508-432-0617 I CELL 508-246-2051 I EMAIL,service@capecodoil.com • f
I