HomeMy WebLinkAboutBLDG-15-003016 t:se MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 1/ Avg fr* til OWNER'S NAME (401,0 Part//ti/
GOWNER ADDRESS cre, . A_ TEL FAX 111.11111111
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW& RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-• BSM 1 2 3 ' 4 5 6 7 8 9 10 11 12 13 I 14
BOILERr
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BOOSTER I., I .�.-1 —��� 'i I,
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CONVERSION BURNER — I I—1 I �;.-1'
COOK STOVE —1 h ��I —I
DIRECT VENT HEATER I II I Ii I, {; I II �' I
DRYER I I I I I I , I II II I I'
FIREPLACE I-1 I
FRYOLATOR 'i —�i II I 1 h—J I
FURNACE —II-1 ) I; i I t t, I I
GENERATOR 1 I �(!
GRILLE � i i cIi 1 I \ G I
INFRARED HEATER —7I1 II— I II I I II I_ k I
LABORATORY COCKS —� --- —I` I
MAKEUP AIR UNIT I; F I h I ! 1
OVEN1�I
POOL HEATER k I —�I—t Ii-1
ROOM I SPACE HEATER I, I 1 ) IIi I I I . L - II�
ROOF TOP UNIT I 1
TEST 7--. ,-1-7--i , :-----1
UNIT HEATER 1 j11-1 ; I 1 II ;
UNVEN ED OM HEAITER f. f I S I —I
WATE R TE /p I II� ,—I
OTHER L w�b0 � Tse I Q i —I h
NU U of 7�14 ,:7-71_._ _
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EUILDiN , DI PARIMENT , i -..
--- - - INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY p 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 ONLY: 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 true and accurate to jest of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi h all P nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GAS-FITTER NAME R Peter Checkoway LICENSE# 13417 `iIGNATURE
MPI MGF❑ JP El JGF❑ LPGI❑ CORPORATION❑# — PARTNERSHIP❑# LLC CP
COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Road
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net
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