HomeMy WebLinkAboutBLDG-16-006840 . . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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_ JOBSITE ADDRESS /,J a/413/e)Oen/ O21 vs LI OWNER'S NAME ,sake 640'213024
GOWNER ADDRESS Awl-it TEL FAXL
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL '
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CLEARLY NEW: RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑
APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I 11 _ I 4 '
BOOSTER , 1'_ _ ii II ll i'__ a _ i _ a 1,
CONVERSION BURNER a 1I_ L ^I
DRYETVEENTHEATER I' �1 rr r 1 1,
FIREPLACE 4 I
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FRYOLATOR +i '�i _ iminsit*[ ilmisi�li Iasi _ --
FURNACERCEOR ,, INK it ;welt Jrl�
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NFIRARED HEATER ,r lII �,i - ,� '41- _ ILA
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MAKEUP AIR UNTORY OCKS
OVEN7 11 i, a i, _
POOL HEATER I ', _ i. iu I
ROOM/SPACE HEATER i i' 11 i i I i i
ROOF TOP UNIT 1 p i,. r
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UNVENTED ROOM HEATER T __
WATER HEATER �l�
UNIT HEATER ,� it � I i
OTHER 1 7 T i I ir— TJ—T - 1,
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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 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND 0
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 0 AGENT 0
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 of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with II nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway ' LICENSE# 13417 NATURE
MP E MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑#I LLC❑#
COMPANY NAME:LCheckoway Enterprises ADDRESS 111 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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