HomeMy WebLinkAboutBLDG-18-002305 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
~ � 7 PERMIT#la& -vo?3(S"
_ CITY (/1/ T� /Y)014734- MA DATE/e.r �+
JOBSITE ADDRESS S A,Qc1-1S E ROAD OWNER'S NAME-7 /? lTZ Gar i;)
GOWNER ADDRESS SA-M� TEil 7T ' 2b 8-f 3/2-FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL +
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO /
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
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
(ir9 i
POOL HEATER _l
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
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 + 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 0 Y: 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 e and; tot he b t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c piianc t II P rti ov ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M SIGNATURE
MP + MGF JP JGF LPGI CORPORATION + # 3734C PARTNERSHIP # LLC #
COMPANY NAME: HALL OIL COMPANY INC. ADDRESS 435 RT 134
CITY SOUTH DENNIS STATE MA ZIP 02660 TEL 508-398-3831
FAX 508-394-3068 CELL EMAIL halloilcompany@gmail.com