HomeMy WebLinkAboutBLDG-18-005048 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
av -sr: CITY �Jy0k�—� ;r MA DATE j -I L-I g PERMIT#/ �J`//'et 7 G
JOBSITE ADDRESS J D 7 Scrkc,J&s- /Qc) OWNER'S NAME eLE/v.4 I pv4
GOWNER ADDRESS S A-me TE7?9 2.443 FAX
TYPE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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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 J
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
�POOL HEATER ' t' ((��� r�
ROOM I SPACE HEATER L. G� 3/J
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 a and a to t the b t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c plianc t II P rti rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _— l
PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M SIGNATURE
MP ' MGF JP JGF LPG' 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
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