HomeMy WebLinkAboutG-12-015 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
1=- iii— i
F_ 1711= City/Town: S / 41119 Permit/fa/2 C
7_41._--r,wa (rte/{ /� V�} MA Date: 7A/1 / -0/
Building Location: [J arr. 67 Q 0 lb Owners Name: /W6yyde.. 74 62 ke,
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential El,
New:0 Alteration: 0 Renovation:0 Replacement:(] Plans Submitted: Yes 0 No❑
FIXTURES
re re vi
et F- yce
ix
12.1 w
V 2 N
m 's� Q° IL W U co I- o = z W RECEIVED
O W y K g O Se FW- X W K O i-'
ce y cWi z CA go o a w 2 6 ..UL 0 8 2011
iL
W W QZ W Z Z co w O UJ S Z W K
> W } K a J I- FF O 2 J 0 LL F W F W W
O g: } O Q a la
e 6r> O 4Z O in f- ] z F- s BUILDING.DEP!.
V o o LL a w s = ..1 o a fL clF' 3 7 > 3 o EY
SUB BSMT.
BASEMENT
15' FLOOR '
2"FLOOR
3"FLOOR
4'"FLOOR
5'"FLOOR
6'"FLOOR
7'"FLOOR
8'"FLOOR •
Installing Company Name: CHECKOWAY E1 I EH'HIS:S Check One Only Certificate#
11 SCARGO HILL ROAD
Address: DENNIS,MA 02638 0 Corporation
CltylTownrnq-VIC-1911 State:
0 Partnership
Business Tel:
Fax:
Firm/Company
Name of Licensed Plumber/Gas Fitter: R. PETER CHECKOWAI
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yetilg No❑
If you have checked Yes,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy ta 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 waives this requirement
Check One Only
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
By checking this box 0: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 pe Issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 oft oral Laws. ..
9y _ hipof License:
_ OPlumber -
Title
paGFitter Signature of L ceT need ber/Gas Fitter
Master
oityilown0 man License Number: 37/7
(OFFICE OFFICE USE ONLY) LP Inst 0 LP Installer