HomeMy WebLinkAboutG-11-547 ‘S. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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' 11_ City/Town: �2ntUnfi MA. Date: f low l << Permi
Building Location: /r 13(r(Ea A' Owners Name: &f1 .) /J T W D 0 D
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Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential tn
New:0 Alteration:0 Renovation:0 Replacement:W Plans Submitted: Yes 0 No 0
FIXTURES
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Installing Company Name: CHECKOWAY ENTE Check One Only Certificate#
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11 SCARGO HILLROAD0 Co
Address: CttyDE NII MA 02818 State: Corporation
Business Tel: 1 ❑Partnership508-385-191
Fax: Cr2Q 3pr-ei
Name of Licensed Plumber/Gas Fitter. R. PETER CHECKOWAYI: '0-Firm/Company
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Ye;11 No 0
if you have checked Ygg,please Indicate the type of coverage by checking the appropriate box below.
A liability insurance policy [ Other type of Indemnity 0 Bond 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 waive,this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box LI;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and ChapterpermitOn General
for this application will be In
nY 142 a 0eneral Laws.
By.
Type of License:
lumber
Tills Gas Fitter Signature o Lice lumber/Gas Fitter
Br Master
City/TownJouInsyman License Number: 47,07
APPROVED(OFFICE USE ONLY) 0 LP Installer
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FINAL INSPECTION
BELOW FOR OFFIC USE ONLY PROGRESSINSPECTION(SI
FEE: S PERMIT
APPLICATION FOR PERM TO DO GAS FITTING
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NAME&TYPE OF BUB DING
J OCATION OF BUILDING
SKETCH
PLUMBER GASFITTER.LP INSTALLER
LICENSE NUMBER:
PERMIT GRANTED 0 DATE;
GAS FITTING INSP •R