HomeMy WebLinkAboutBLDG-19-001450 rz-a
.t: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
zr� U
r CITY YARMOUTHPORT MA DATE 915/18 PERI/1114 6ux -/f'Od I/io
JOBSITE ADDRESS 27 BOXWOOD CIRCLE,YPT OWNER'S NAME LINDEN WOOD
GOWNER ADDRESS SAME _ TELT 508362-8214 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:U PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-. BSM 12 3 4 5 6 7 8 9 10 11 12 13 14
BOILER -
BOOSTER — - -- --- - -- --
CONVERSION BURNER - -
COOK STOVE - 1 — -- - — —
DIRECT VENT HEATER - ' -
.
DRYER
FIREPLACE - -- --- -- - -- --- -- — --� --- --
FRYOLATOR - - -- --- -- --- -- — ---- -- ---
FURNACE - - - - -- - - -- __ _ ._ _ -
-
GENERATOR -- -� - _ __ - _— ....
- . ...
GRILLE
INFRARED HEATER - --- --- — — f- — —
LABORATORY COCKS
MAKEUP AIR UNIT -
OVEN - ---- -- — - - -- — - -- _ -
POOL HEATER
ROOM/SPACE HEATER
--- --- ` ---
ROOF TOP UNIT
TEST -- - - - - -
UNIT HEATER - -- -- ---- __ —
UNVENTEDROOM 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 D 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 0 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 Ei AGENT
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and sdon nation I have submitted or entered regarding the application are true and accurate to th-,'--'- of my knowledge
and that all prunbing work and installations performed under the permd issued for this application will be in compliance with all P- i ' provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME RPeter Chedcoway LICENSE# 13417 / = •TUBE
MP 0 MGF Li JP❑ JGF❑ LPG!❑ CORPORATION 3# PARTNERSHIP❑#1 _ _ - LLC D#
COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd
CITY Dennis j STATE MA ZIP 02638 JTEL 508-385-1911
FAX 508-385-6858 CELL 508-135-9993 :EMAIL checkent@comcastnet
- �8
7 /1 /-6