HomeMy WebLinkAboutG-14-363 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS Marfa i�_a OWNER'S NAME Agin- /AVn' I
GOWNER ADDRESS 5;90�e-- !TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATIONS • REPLACEMENT:C] PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I I I' I I 1 1
BOOSTER
CONVERSION BURNER I Ii I I�
COOK STOVE R,,,
I 1, f „ 1
DIRECT VENT HEATER f i I I I
DRYER I ; ISI
FIREPLACE + 1 �,
FRYOLATOR
FURNACE I 1—I
GENERATOR -- - I 1 1 —7I
GRILLE (--If—II I I
INFRARED HEATER I
LABORATORY COCKS i
MAKEUP AIR UNIT et (—
OVEN
POOL HEATER , i i 1,
ROOM/SPACE HEATER1 1 imi
ROOF TOP UNIT1,:f-1 :1
TEST
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UNIT HEATER I I
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UNVENTE ROOM HFATFR , Rs ;r
WATER HI I , ,
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BUILDING D , ENT INSURANCE COVERAGE
I have a c B . - •---'=•-�'. .. ' •r its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q 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 El
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 IR •GENT ❑
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 t.: .:- of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with I Pr - provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE#1-MaITI �GNATURE
MP Q MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION at PARTNERSHIP 01/ 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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