HomeMy WebLinkAboutG-14-342 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
rG== Pr
taste CITY renneuv-eAar ( MA DATE /0iokq 1 PERMIT# b/9— 3V z
JOBSITEADDRESS 194 purer l;)4 gm..) Inc, (OWNER'S NAME nO -cern RFai.
GOWNER ADDRESS cc/int (TEL tin oi ii 161 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL1
PRINT
CLEARLY NEW:E] RENOVATION:❑ REPLACEMENT:Th PLANS SUBMITTED: YES❑ NOD
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 1011 12 13 14
BOILER I '; I I I I f'
BOOSTER -_.- II I I1 ---1 1-1
CONVERSION BURNER PI :14,
COOK STOVE i dl
_____,
DIRECT VENT HEATER I
DRYER I
FIREPLACE _ il ,
E_ I 5 i 1 -I 1
FRYOLATOR �t
FURNACE c l lr- 1r r�M :r 1-1
---
pc
-sr— I
GRILLE �r _ II
(� E UI '.' 0LABORATORY COCKS IF
--
MAKEUP AIR UNIT �� 1�� I f1
OVEN -' t I i'—) r
POOL HEATERl; —f�, � L
ROOM 1 SPACE HEATER t- r '' • -ir , I in—
ROOF
TOP UNIT
�1 IefO °-
.ter i
TEST I ,
UNIT HEATER r_ i '
UNVENTED ROOM HEATER -
WATER HEATER ` I _ _ I
OTHER r r ..._.lr r- L
pi ii,1
lr -, �r if 1 1 ,r 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El 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 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 ' rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE#17471:11 SI RE
MP Q MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION at PARTNERSHIP❑# LLC❑#
COMPANY NAME: Checkoway Enterprises ADDRESS 11 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