HomeMy WebLinkAboutG-14-635 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�:RV CITY S ygamft cat ( MA DATE /97.211); PERMIT# G/y—G 3C
JOBSITEADDRESSV).. —(4-R0redd0 flit sy IOWNER'S NAME f47E,t. (' nirt //4 _
GOWNER ADDRESS •cPOrPte,..- TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIALtr
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CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 1 8 9 10 11 12 13 14
BOILER - 1 1 I I .1_- 1 ]
BOOSTER -I I I
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CONVERSION BURNERP
COOK STOVE lb-9 1 { ]
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DIRECT VENT HEATER I I 1 _
DRYER _ 1 I' III I j
FIREPLACE I I I -I
FRYOLATOR F 11 _ i �-1
FURNACE —
1 I I
GENERATOR . 1 iR I
NGFIRARED HEATER I I I ,_ 1 1j 1 I
LABORATORY COCKS i I
MAKEUP AIR UNIT Iip ]
OVEN I I 1 1_ ..d
POOL HEATER ]
ROOM I SPACE HEATER 1 1 I i' a I f
ROOF TOP UNIT 1 ) _ _fl h�
TEST 1 l . i
UNIT HEATER L 1 I_ ,. j I -- I 1 1 ii .. ]
UNVENTED ROOM HEATER
WATER HEATER :I , 1
OTHERII
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INSURANCE COVERAGE !d :- '-
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG Ch.142 YES Q NO ❑
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I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO Cl..,.�.I L
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LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ "ThifFETO Il0j.0
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 Pee provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 i GNATURE
MP ED MGF❑ JP JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP 0# 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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