HomeMy WebLinkAboutBLDG-23-9582 cr- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
MA DATE1
— —f
"N1= CITY ; � w�...... -... ...__... - -
� b a _ PERMIT# gLDG -2-3 --9C3Z
JOBSITE ADDRESS' "" "-
ec- S�c� �'
'OWNER'S NAME ' Sti' �\ •
OWNER ADDRESS "
TYPE OR TEL FAX L.. ---_...
PRINT OCCUPANCY TYPE COMMERCIALI EDUCATIONAL RESIDENTIAL(
CLEARLY NEW: RENOVATION:' REPLACEMENT: --".
PLANS SUBMITTED: YES I NO'.
APPLIANCES 1 FLOORS-.
BOILER ..EISM
1 . ,. .3 4 5 _ 6 7. . . .. 8 9.. t0 11 12 13 14
BOOSTER
•
CONVERSION BURNER
:.
COOK STOVE
DIRECT VENT HEATER ..._... ......._ ,- -• -_ __ .._...
DRYER • : .... .
. .... . ... .. ..
FIREPLACE •
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"! • •
•
i.
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 .... : 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 i- 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 accuratLto t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In compli ail ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME:David W.Roderick Jr. i LICENSE#196
___ SIGNATURE
MP' MGF' JP JGF _ LPG CORPORATION #
PARTNERSHIP'" -......-- ` �"" "
COMPANY NAME:;Cape Cod Oil&Propane - (ADDRESS:POBox99_
3 ._._...-.... ._ __.._....._._._......_... ._.1
CITY +Provincetown --
STATE! MA (ZIP 02657 . - -_.-_____--_....-,._----..I
,.._-._—.-----.._...- TEL 508-487-0205
FAX i508-432-0617 - - ._... .
CELL508-246-2051 -_---- -
EMAILaervice@capecodoil.com - - - i