HomeMy WebLinkAboutG-13-1062 -, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 49 CCOJE2 L#4 OWNER'S NAME (gig -TW6ll(3Cy I
G OWNERADDRESS c• (mirk f'r'2 ( Caul-wt./ Of MTh TEL qnQ.t(YP'59.16 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL]
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:gI PLANS SUBMITTED: YES NOD
APPLIANCES 2 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOOSTER I i i i I, , I , I
CONVERSION BURNER J' III
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DIRECT VENT HEATER I111 ilia si
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MAKEUP AIR UNIT los 1 Ali
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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 Q NO 0
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 t. r best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance 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 doe IGNATURE
MPD MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIPE# LLC❑#
COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Road
CITY Dennis STATE MA ZIP 02638 TEL 508.385-19111
FAX 508-385-6858 CELL 508-735.9993 EMAIL checkent@comcast.net �
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