HomeMy WebLinkAboutBLDG-23-9715 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE;\ PERMIT#
JOBSITE ADDRESS r OWNERS NAME ;S:)e_ •
G OWNER ADDRESS 1 _ScoNe__
TEL;Sc6-"-•—7/ k 04\ FAX!
TYPE OR
OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL 3 RESIDENTIAL LL.—
FR]:NT
CLEARLY --• •-- •--
NEW:: RENOVATION: REPLACEMENT:; PLANS SUBMITTED: YES NO
APPLIANCES t FLOORS—, NM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER • •
BOOSTER • r.
. : . . - •
CONVERSION BURNER ;
COD:STOVE
DIRECT VENT HEATER • '•
DRYER
FIREPLACE FRYOLATOR • • •
FURNACE • • • •
GENERATOR • . . . . .. .
GRILLE • . ' • .
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN .
POOL HEATER • •••••••••••
ROOM/SPACE HEATER • ••. : • : • R. E-C-E .I V E--D I •
ROOF TOP UNIT
TEST . . . . . .
. (.DEc_ ___ •
UNIT HEATER _ 01202
UNVENTED ROOM HEATER r
• • . . • ". . •---
WATER HEATER • . • • • ; BU Lt7iNe DE ART EN I
• •
•
. . . . .
•
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES g NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY St, OTHER TYPE INDEMNITY BOND I
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 1— 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 accurate to t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In compliance nent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
•
PLUMBER-GASFITTER NAME:David W.Roderick Jr. I LICENSE#19671 SIGNATURE
MP MGF' JP JGF LPG!: ; • CORPORATIONS # PARTNERSHIP # LLC; #3
COMPANY NAME:[Cape Cod Oil&Propane _ • I ADDRESS!PO Box 993
CITY IProvincetown I STATE! MA I ZIP 02657 I TEL;508-487-0205
FAX I CELL; EMAILseMce@pecodoIl.com
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