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' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Ts j CITY garm,fiv-rti I MA DATE 'd 1.22./ l PERMIT# 'n6-R-dd/f
JOBSITE ADDRESS 38 All. Yn l N rhr I OWNER'S NAME A KOCCO�• f b I
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OWNER ADDRESS 3Cavil-0d Ccetain, Saidna, t' 11E 16Q3. C/3Q •[(.,d l FAX) f
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ N0Er
APPLIANCES 7 FLOORS-. BSM 1 2 3 0 . 5 6 7 8 9 10 11 12 13 m
BOILER fi•IimiISI mum mr _ , ice ice.
BOOSTERi'� J�+ ; _1 � )WWW!
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CONVERSIONBURNER �I_��M�r �!i�_ j�'iP'�j�,����i�')�
COOK STOVE i��i ��_i��.11. __aImIaa
DIRECT VENT HEATER I_---:ft_'__is a I_111111
DRYER �� �����_ '_I�4 1 NM
FIREPLACE _It i_ _,a alate;a� .
FRYOLATOR
FURNACE ■U'I;LINAC 011MlanlIMMIC-1 , ice M—'
GENERATOR Maa-M,MITIffrarilliiiMIIMUMMIIMI'.
GRILLE __ _qc_ l 01.1,111. 01111S
INFRARED HEATER ^j { ;i� '�� �_=1•Ia1.1.
LABORATORY COCKS :11111011111,1111.111lPM, 't; f )gala ar
MAKEUP AIR UNIT _'ilei FJ' I .M111.1J
OVEN si�il_Ii_i✓!M:_Iatilium� .
POOL HEATER [MIT_--misinimisoititair,—,
ROOM/SPACE HEATER
ROOF TOP UNIT UNIT141111,111111,1SWISIN,��'�7♦l��f �I
TEST _rnraw solwma _iJ_]l• i
UNIT HEATER I•111WW.iHIjILIjNIII 1111111.NMI
UNVENTED ROOM HEATER _—il_ )_;—;_rte _i _nitmin'
WATER HEATER _',fel_1111.N_IMMISWINOMI
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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 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 two and accurate t';8".: of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be In complia •.= with allt-- ent pmvision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R.PETER CHECKOWAY LICENSE# 13417 jor NATURE
MP El MGF❑ JP El JGF LPG!El CORPORATION Q# 4008 PARTNERSHIP 0#1111.11111111111 LLC D#
COMPANY NAME: BOUROUE HEATING 8 COOLING CO ADDRESS 1199 PITCHERS WAY
CITY HYANNIS STATE MA ZIP 02601 TEL 508-790-2887
FAX 508-771-9696 • !CELL,508-735-9993 !EMAIL info@bourqueheatingand000iing.com
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
IYes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT# — //�
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