HomeMy WebLinkAboutG-13-927 -• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 111 Wt
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GOWNER ADDRESS C{O ego), Sr Au.4Aar' !r acm-o1 TEL 9(-4 0o - qø'3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIALY
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CLEARLY NEW:' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER '' _ I I, I I I i I-
BOOSTER r !II‘ I
CONVERSION BURNER I IIIIII i II 1
COOK STOVE
DIRECT VENT HEATER i _ =�I
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FIREPLACE IST 1 M i- 1.Tat ,
FRYOLATOR I—I �r— �S1— ♦SISiMTl
FURNACE 1—I' Maw
GENERATOR
GRILLE II- 1n- li I� ='EI 'I
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INFRARED HEATER _ 1 1,,�M I .
LABORATORY COCKS
MAKEUP AIR UNIT n _
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POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT' TEST I ,i
UNIT HEATER i-11 ���m�an[MIS
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UNVENTED ROOM HEATER Ir
WATER HEATER I, ,_ i r I
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INSURANCE COVERAGE ee,j "
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 Q OTHER TYPE INDEMNITY Li 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 ❑ AGENTS(
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 tot est o knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit al P ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE#1-13-117-1 IGNATURE
MPD MGF❑ JP JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME: Checkoway Enterprises .ADDRESS 11 Scargo Hill Road ^
CITY Dennis STATE MA ZIP 02638 TEL 508-300115 �7 P1q 1I
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FAX 508-385-6858 CELL 508-735-9993 EMAILI checkent@comcast.net 111 ! •f $ I 111
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