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MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
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a"F�g> CITY I ,-- ._._..___ _____.... ____.._.
4 nav Z MA DATE; _ .__.. _._ PERMIT#43L DG Z3--c73 7y
JOBSITE ADDRESS' er G'� A,/ _..... ... ._......
G ��fa�) 'OWNER'S NAME
OWNER ADDRESS i "
TYPE OR Tap___. - -_._.-----------•F� ...___-_---__-----
pT OCCUPANCY TYPE COMMERCIAL I.� EDUCATIONAL : -
CLEA.RLY _ RESIDENTIAL
NEW: RENOVATION:' - REPLACEMENT:
APPLIANCES Z FLOORS-4 PLANS SUBMITTED: YES i --.� NO'
BOILER BSM .1. 2 3 4 5 6 7 8 9 10 11 12 13 14
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPIACE ; .... .
FRYOLATOR
FURNACE
GENERATOR ::...
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN ,
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT -- " " ---
TEST
UNIT HEATER }
UNVENTED ROOM HEATER
WATER HEATER
OTHER ! . ._. -
P , _
c,-u-S /:`A,e o T-
raci `t-ry
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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER i`- AGENT? -
I hereby certify that all of the details and information I have submitted or entered regarding this appllcat are true a r ccu
and that all plumbing work and Installations performed under the permit issued for this application wi I complia h e best of y knowledge
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws. c Went pro ' of the
e
PLUMBER-GASFITTER NAME;David W.Roderick Jr. ! LICENSE#i
-- — SIGNATU
MP' MGF' JP: JGF`- LPG' CORPORATION • #: '
PARTNERSHIP #; .. _........- . .. ... ....
COMPANY NAME:iCape Cod Oil 8 Propane j ADDRESS APO Box 993 . .- __ _ ......_._. ...... _. . ...
CITY ;Provincetown ---•- _.__..,-..,...--
STATE! MA ZIP 02657 -_-_ I TEL 1508-487-0205
FAX;508-432-0617 - - -__._.._..__.........
CELL 508-246-2051 i EMAIL}service@capecodo_ I_ _.