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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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Ali CITY r(.kJ. MA DATE 3-'1 5-1 PERMIT# G`'Y` /67
JOBSITEADDRESS 5-41 C►}LCK*Oa..a frf IOWNER'SNAME edemahi jyft.-rtg.mg/4
GOWNER ADDRESS 6-941- 2._ TEL[jyf 77J- /r / ,FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL❑ RESIDENTIAL 8'
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CLEARLY NEWS' RENOVATION:❑ REPLACEMENT:CD PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 I I I
BOOSTER ff
CONVERSION BURNER f-1 I Ij P.
COOK STOVE 1 1 1 —1 - T',
DIRECT VENT HEATER I I
DRYER I I I I 1 1 1 1 1
FIREPLACE --1 I
FRYOLATOR , —, I -I 1 1 l
ill ,FURNACE ,--) . 1 ri i I I II
GENERATORJI_IiGRILLEIINFRARED HEATER II LABORATORY COCKS MAKEUP AIR UNITI—I
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POOL HEATER �j
ROOM I SPACE HEATER1111111111111,,11-1m.S[
ROOF TOP UNIT pi
UNIT HEATER
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UNVENTED ROOM HEATER _ _ 1 _ I
WATER HEATE• �7 aia ;!pop"
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INSURANCE COVERAGE
I :ve • -!:ir,° ��r olicy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
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I IF a'-.-• - ES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a 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 A
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to theof my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all P-rti j, •rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 URE
MP MGF❑ JP JGF❑ LPGI❑ CORPORATION 0# 1PARTNERSHIP❑# LLC 0#
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