G-13-1030 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
''a,gor eCITY (Ai;IA 1/4151) I MA DATE 511/ hi I PERMIT# 4:49—J6+Y3d
JOBSITEADDRESS 6 c<(Loa k4•1) (24 IOWNER'SNAME ore\ vsves
G OWNER ADDRESSj �j-jig a( 1*MU 041 ITEL? $7 -I -,76f'Y- IFAX
TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL❑ RESIDENTIAL 12
PRINT
CLEARLY NEW:❑ RENOVATION:CI REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER , 1 1 i Q I - T I I
BOOSTERl
CONVERSION BURNER 1� II )_ 5.
COOK STOVE
DIRECT VENT HEATER is__
FIREPLACE iI �I�I�
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FRYOLATOR (- ;
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GENERATOR 1 .._ _ 1 _,• i. �r'c
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INFRARED HEATER i I-, i ` f Ir
LABORATORY COCKS �� a C r .,.- I
MAKEUP AIR UNIT
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POOL HEATER 1 r ( 1 1 i 11h -
ROOM I SPACE HEATERI (I 7-71.ROOF TOP UNIT r a, I 11 (I j
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UNIT HEATER 7 �I 1111111111111111i M 1t-lin
UNVENTED ROOM HEATER
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WATER HEATER _ 1 1, IS INET T I Ii —
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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 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q 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 th- •- 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# 13417 /. TURE
MP LI MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION El if 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
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