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HomeMy WebLinkAboutBLDG-23-9393 ,.=s—_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO t - �`i PERFORM GAS FITTING WORK flc 4,.g1� CITY i �0.cTc v . F MA DATE az.3.) PERMIT#/�L/. ZZ_j3__3 JOBSITE ADDRESS f v� rl1C C::Wrest '- -�------ � -, p --- G - �'I �" OWNER'S NAME � AncX .. . `. . OWNER ADDRESS i _ _ �" E OR TEL 5r6-%-i-z• I zF1� FAX I.'.________--_-.,-- pT OCCUPANCY TYPE COMMERCIAL I CLEARLY .. EDUCATIONAL '. RESIDENTIAL NEW: RENOVATION:' REPLACEMENT: APPLIANCES 1 FLOORS �u v©©© PLANS SUBMITTED: YES I NO' BOILER ®®®®�����0 10 m®®� BOOSTER ®®®® ®®®®®�® CONVERSION BURNER ®®®®����®®�®®®® COOK STOVE _TI.— ®®— ____ DIRECT VENT HEATER ®®®®®®���__-�_- DRYER raiummimisiringimommialimaimit ®®®®®®®®®®®®®® ®®®®®®®FRYOLATOR -- ® ®®®®®®® GENERATOR ® ®�®®®®®®®__ 5RTITriminivinia.m.rinnir......- Ej® ®® m®®®®LABORATORY COCKS ® �®�® MAKEUP AIR UNIT �����®® ®����� OVEN ®®®® ®®®®�®®®® POOL HEATER ®®�____ _®® IMIIMIIIIMII ROOM i SPACE HEATER ®�—���®®®�®'�_ ROOF TOP UNIT >�®®®® ®®® �® � ®®�®®�11�11111 �®®��1® UNVENTED ROOM HEATER ®�®®®®®® _ llill WATER HEATER_ ---- —_ __ _OTHER-!___..._. --____.______.._...—�®®_� � .MN® _.... .._..._____-_------_...®®®®®®���� �� MN . . ®®®®®®®®®®��® ®®®®���®®�� ®® 111111®®®®-®®® I have a current liab�insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW YES ENO LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY t_. BOND I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not ave the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature_orthis permit application waves this requirement. p c --$RE OF OWNER OR AGENT CHECK ONE ONLY: OWNER i I herebyce AGENT ' -- of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowled e and that all plu ;,o g work and Installations performed under the permit issued for this application will be in compliance with all Pertinent provision o Massachuse�_- tate Plumbing Code and Chapter 142 of the General Laws. g PLUMBER-GASFITTER NAME David W Roderic Jr. - - f the LICENSE#1967 1 SIGNATURE MP' MGF' JP i JGF;-.. LPG' 3 • CORPORATION i _ #; _ PARTNERSHIP' # -• -- COMPANY NAME:Cape Cod Oil&Propane LLC I .. # ----_...__ -----..-_- — - ADDRESS PO Box 993 __... ..._.._._. ......._._ ._1 CITY +Provincetown __.. -----_.._ STATE MA ZIP i02657 --- -- _ ---...I ....---.._—- --- ..._ ._.. .__.-.----�TEL�508-487-0205 FAX 508-432-0617 _ ._..._.__......... CELL508-246.2051 EMAIL service@capecodo i L^COm -_.._. — . 1 sad) cell. e 6546cL 9 COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE LP GAS INSTALLER DAVID W RODERICK JR 91 ROUTE 137 �-, PO BOX 1322 HARWICH,MA 02645-2119 W 967 05/01/2024 .206583 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER