HomeMy WebLinkAboutBLDG-19-1588 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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TYPE OR OCCUPANCY TYPE COMMERCIAL ( ED ATIONAL 0 RESIDENTIAL ID
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CLEARLY NEW:I4l RENOVATION:DI REPLACEMENT: PLANS SUBMITTED: YES NO[✓(
APPLIANCES 1 FLOORS-6 - BSM 1 2 3 4 _ 5 6 - 7 8 9 10 fl 12 13 m
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COOK STOVE —Omtraftif_a_ af_al_—
DIRECT VENT HEATER 11.11.11,1WIMIIMIIIMIL 111.5? __
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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 0 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY EL 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 true and accurate I•l'• of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be In complian.-with al -- ant provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r
PWMBER-GASFITTER NAME R.PETER CHECKOWAY LICENSE# 13417 der NATURE
MP Q+ MGF 0 JP❑ JGF❑ LPG!❑ CORPORATION 9# 4008 PARTNERSHIP 0# LLC❑#
COMPANY NAME: BOURQUE HEATING&COOLING CO ADDRESS 1199 PITCHERS WAY
CITY HYANNIS ( STATE MA ZIP 02601 TEL 508-790-2887
FAX 508-771-9696 1 CELL 508-735-9993 (EMAIL into@bourqueheatingandcooling.com
BOUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yea No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑ •
FEE: $ PERMIT#
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. -PLAN REVIEW NOTES ' '
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