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0:: . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSREADDRESS 3 :1-13\1{4 )L}- IOWNER'S NAME .-"biONItl fri,A(Ac L i
G OWNER ADDRESS (oti 12((,@ L St I,A/130y!6-J-U0 ITEIJ Sob-hi'-"Oa,j IFAx
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 9 RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 9 NOQ/
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INSURANCE COVERAGE
I have a current Jiabilitv Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 1]NO 9
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
liABILITY INSURANCE POLICY 9 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 ❑ 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 t• t of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be In complian•: with all -- ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R.PETER CHECKOWAY LICENSE# 13417 der NATURE
MP 9 MGF 9 JP❑ JGF❑ LPGI 0 CORPORATION 9# 4008 PARTNERSHIP❑#— LLC 9#
COMPANY NAME: BOURQUE HEATING&COOLING CO ADDRESS 1199 PITCHERS WAY
CITY HYANNIS STATE ISJZIP 02601 TEL 508-790-2887
FAX 508-771-9696 . CELL 508-735-9993 EMAIL Info@bourqueheatingandcooling.00m
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMITt � a/9-3
❑ ❑ f
FEE: S PERMIT#
PLAN REVIEW NOTES
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