HomeMy WebLinkAboutG-14-988 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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��blge CITY V/ .�Ila/djw.lS13 ! MA DATE 46,)9 !PERMIT# 617' 9W.
JOBSITE ADDRESS cpr j4euANt PA773 14y 'OWNER'SNAME j1.159,4 6(2.4,)
GOWNER ADDRESS as-CTnn,2_--et_ fZ<k loAxTbd 0 1I $TEL tin- 1017 FAX .
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:Ell 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 1 I .1 1 1 1 i 1
BOOSTER 1, —1_;
CONVERSION BURNER —r I', I, , , _ 1,
COOK VENT I
DIRECT VENT HEATER I[ , �I Si
DRYER
FIREPLACE W I I
FRYOLATOR r 1 +IMI I I I
FURNACEi0
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GENERATOR 1 1 l 1-
GRILLE 'I I i I_
INFRARED HEATER I 1 I
LABORATORY COCKS -tel 1 I
MAKEUP AIR UNIT I i I, I I
OVEN
POOL HEATER __ I
ROOM/SPACE HEATER —I I
ROOF TOP UNIT I
TEST I'
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UNIT HEATER is..... _p
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UNVENTED ROOM HEATER [ ] l^
WATER HEATER I
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ 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: 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 b- •f my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pe ;r( . ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE#113417 . 1 a T RE
MP EI MGF❑ JP JUL] LPG!E] CORPORATION EP PARTNERSHIP EP LLC❑#
COMPANY NAME: Checkoway Enterprises ADDRESS 111 Scargo Hill Road E t E •
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735.9993 EMAIL'checkent@comcast.net r� PP
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