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HomeMy WebLinkAboutBLDG-17-003094 m �, cie MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE /2 /- PERMIT#///�7 - 5 CITY 1✓t. �f � s` �� �h 'r►'�GkTI Y � � ( JOBSITE ADDRESS n -` /�` �� ,L/��t=;��.�t� �J OWNER'S NAME �L�ry 1-�� G OWNER ADDRESS 1/Z C'`f�Gi1 Si' M)s7U L C J TEL 7L/'7FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL � PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z 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 OVEN POOL HEATER ROOM/SPACE HEATER " )0 ROOF TOP UNIT PP )7 ; : G TEST - UNIT HEATER UNVENTED ROOM HEATER Y ve4 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 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-rt v' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � / PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M I 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 ZAP( MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK IV CITY L 2 c rytOcc.. _ . MA DATE /2 /- PERMIT# JOBSITE ADDRESS 2 OWNER'S NAME bosi iQ-L j _ OWNER ADDRESS II Z _._. , ... 7., JSTfl L C.J . ._ ... TEL 94:7Jk 7717FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ._, REPLACEMENT: . PLANS SUBMITTED: YES NO APPLIANCES Z 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 OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST ' E C - . UNIT HEATER �. UNVENTED ROOM HEATER ;. 1 _ RI ; • WATER HEATER `-+v OTHER 5 . qy• • 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. : 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 a. J e of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in • plian = All P••• ' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , ./ V- 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 C�