HomeMy WebLinkAboutBLDG-19-002012 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS ( Ll 4.:lOtG Lot n — OWNER'S NAME Lo.(,r, G n c,,/c
OWNER ADDRESS 54,,•,� TEL 5vy 965 -/96s FAX[
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:Er RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS—' BSM 1 2 3 4 56 7 8 9 10 11 12 13 14
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DIRECT VENT HEATER ' T 1 — - •__,:ini
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LABORATORY COCKS
MAKEUP AIR UNIT r r 1 I IL lr 'I _ 1
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POOL HEATER 1 1 Mi
ROOM/SPACE HEATER I II __ _ �' rImi I
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UNIT HEATER I II ill_ _IIS ilii
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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 I]NO D
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D 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 ■ h GENT ❑
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 to the •- of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe . e• •rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 -t•TU RI
MP Q MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME: Checkoway Enterprises ADDRESS! 11 Scargo Hill Road '
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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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