HomeMy WebLinkAboutG-14-931 _• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
tr$°1;=# CITY (/t1.k fiftMd UV I MA DATE . 2d).343 I PERMIT# 6y- V$1
JOBSITE ADDRESS pi 0 ,‘Apzingsn OWNER'S NAME /f4wt1/ 'fir 1n/ I
GOWNER ADDRESS 349 4JM5iOe /1(/ Aim(My/ k hi TEL �{ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7 FLOORS-' BSM 1 23 4 5 6 7 8 9 10 11 12 13 14
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COOK STOCONVERSINE BURNER _ II• I IL
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BOOSTER I \ I I
DDIRECT RYER VENT HEATER -I i r—r_(I I,- II j —I,
FIREPLACE - fl r -1- en r
FRYOLATOR )— t - - — II dl ll_ll 1.
FURNACE II II r . —inn
GENERATOR I I
GRILLE II I IL I I -( -il-1
INFRARED HEATER ` I i ly I l
LABORATORY COCKS T—1 I. T 1I 7 —
MAKEUP AIR UNIT 11—l��(i t. I—I I �--i I_{J-1
OVEN t—II t Ji —I I V I ��I it 11 1—I
POOL HEATER I`
ROOROOF TOP UNI/SPACET EATER —II II I - I I; I 11 I II I II
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UNITHEATER _ 'L'Lr—li 1 Ii I l ;I—,—I
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MIN 1111111 MN MIMI MI 111111111 MI MK IIIIIIIIIII
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Br•- • j',r! ' LivT INSURANCE COVERAGE
I hav• . I • '.l`' - • . . ,'licy or 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 0 BOND [f
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 ❑ 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 be v y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertine, • ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 S� 'TRE
MP Q MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP 0# i 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