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ra MASSACHUSETTS UNIFORM APPLICATION FOR A PERMI TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS `5/ 4,/tor_ GJ yor !OWNER'S NAME L 9u,ifr (/9 t/1 n I
G OWNER ADDRESS „5";,,,,n ca_ TEL,S7if-F6r--'?( !FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAIffi
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CLEARLY NEW ' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ID NO El
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
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BOOSTER 1 M ; AL 1 '
CONVERSION BURNER _ i_ it 1 I li _1
COOK STOVE I ] _ { r �;
DIRECT VENT HEATER I - }
DRYER _ ),_ _A____Ii li I ._ 1,
FIREPLACE
GENERATOR 1 FURNACE 1 ii -,��1
FRYOLATOR I I lI—I� I it I
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GRILLE I 11 !, ; ,
INFRARED HEATER I l ); �; I
LABORATORY COCKS I _ _
MAKEUP AIR UNIT _ 1 _ ; __'
OVEN ); II
POOL HEATER
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ROOM/SPACE HEATER L _
ROOF TOP UNIT I, I
TI_ I
TEST L1 'ki , 'I
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER a )11111, _
OTHER
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INSURANCE COVERAGE l g Ila ;' i if,..._,Id
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 4 YES Q NO i
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IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1_ 1 . . ':J VI'
LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY p Bt ND ❑V,,LC Ns C`„
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Fa'pter-142 of the_ /S °
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 .-1 of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all 13, '--. provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE//1715117-1 e1fITURE
MP 0 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# I 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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