HomeMy WebLinkAboutG-13-569 n c f,_gi
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�, COY EL \�L}/ Ov]1I �I MA DATEraLiL�Z. PE1&flTi17'/.9 — 0
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JOesamc !-ADDRESS" E g 1 /6 4A r f(L' _ OWNER'S NAME&mc ca/k175)71/1 `1
G oANER ADDRESS r`qJ el (Jr gAxeo,i��i-' cgr-fly-Z OI, FAX i
TYPE OR
PRINT
OCCUPANCY TYPE COMMERITpL❑ I EDUCATIONAL❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATIO PLACEMENT:❑ PLANS SUBMfTTEDt YES❑ NO❑
APPLJANCESZ FLOORS-• 89,1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 \,
BOILER w
BOOSTER \
CONVERSION BURNER
1
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE _
FRYOLATOR
_FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN ,
_ . - -
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT, ,
TEST
UNIT HEATER
UNVENTED ROOM HEATER -
WATER HEATER
OTHER , �y— •
1 INSURANCE COVERAGE
I have a merest liability immerge policy or its substantial equivalent which meets the requirements of MGL.Ch.142 -YES l NO 0
I F YOU DECKED YES,PLEASE INDICATE HE TYPE OF COVERAGE BY CIIEtlWIG TIE APPROPRIATE BOX BELOW
LIABWTYINSURANCE POIJCY❑+ OTHER TYPE INDEMITY ❑ BOND ❑
OWNER'S R:
INSURANCE WAIVEIamaraetutthe6anseedoesnottavetheinsigne coagere¢otedbyChapter142ofthe
ttassadmsetts Genal Laws,and that my sigiat me ani permit application'Evils this requirement. -
CHECK ONE ONLY: OWNER I❑ AGENT❑
SIGNATURE OF OWNER OR AGENT ( I
I hereby codify Metall attic details and intimation I have meted or repairs rerdtg this appicak u ate butt aaaa
and �� knowledge
of my wledge
W
and that al pnbig d work ainstallations pewit ions trlmod under the petissued worths application wit he in•• • : •, 2.. , provision dare
. Massachusetts Stale Plumbing Code and Chapter 142 atthe Cenral taws.. . -.' _ .
PLUMBER-GASFLTTERNAME RPeter Checkoaay 1 LICENSE/113417 •. 00 TORE
MP ElMGF❑ JP❑ IGF 0 LPGI0 - -CORPI( ORATION C1 - _ PARTNERSIUP:3 LC Eli
COMPANY NAME Chedcoway Enterprises I ADDRESS 111 Scargo Hill Rd i
CITY --Dennis _. ___ __ .._ I STATE ma DPI 02638 1TEL 506385-1911
FAX 5o8.3854858 CELL 508-7359993 IEMAIL decken - ,
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1 DEC 14-2;2