HomeMy WebLinkAboutBLDG-18-001428 F
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-F3= CITY ('V. jAr rvl�j' f/�j MA DATE 9-f) - 1 7 PERMIT#f 6-10-1 It0 g-
�� JOBSITE ADDRESS 7-Li r4,d c L A OWNER'S NAME &{Q 6grt C V f�D I
GOWNER ADDRESS SA b*V i TELra-77S- 37?6 FAX
TYP EPRINOR OCCUPANCY TYPE COMMERCIAL EDUCRI•,+�AI E�VTIAL
CLEARLY NEW: RENOVATION: REPLACEMENT: ✓ NS SUBMITTED: YES NO
I _
APPLIANCES 1 FLOORS BSM 1 2 3 4 ISC�P 11 3S01p 9 10 11 12 13 14
BOILER
BOOSTER �-ay 1 zTMF"I"IT
CONVERSION BURNER - --
_________
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
, INFRARED HEATER
LABORATORY COCKS
I MAKEUP AIR UNIT
OVEN
POOL HEATER
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 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,
CHECK ONE O : OWNER AGENT
SIGNATURE OF OWNER OR AGENT ,F
I hereby certify that all of the details and information I have submitted or entered regarding this application are e and a e t 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 plianc t II P rti ' ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M
SIGNATURE
MP y MGF JP JGF LPG! CORPORATION i # 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 halloilcornpany@gmail.com
1
1
6
r