HomeMy WebLinkAboutBLDG-15-002097 -a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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C CITY 3v )41-0140 Ifin 1 MA DATE t SO cr PERMIT#D / tv�.
JOBSITE ADDRESS tVea- rZfcrV ? 4! OWNER'S NAME I t ' 672/1/0 r O97
GOWNER ADDRESS 7p= tzriara�iIV 11% TELtpett.,4N ° T ,FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL S
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:IS1 PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER j I, �I - i i I� _ i - ]�
CONVERSION BURNER I-11 1 1-I)_ ,�, Is_ li t. 1
COOK STOVE )� 1_- 11 I
DIRECT VENT HEATER 1 1-1
DRYER II It " ' t�_ �_s
FRYOLATOR 11 1 l�l L 4 _ L
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FURNACE r 1 I — L I I . {
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GENERATOR I 1 II__
GRILLE . 1 1 ; ; i
INFRARED HEATER �. —_. I
MAKEUP AIR UNIT ~ 1
LABORATORY COCKS 1 i �., - �� �, .,,,4� I_
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OVEN 1 1 II— T_ 11__I v a
ROOMPOOL/SPACE HEATER L-EATER lc - ` . I I IL
ROOF TOP UNIT Il 1 I _ ._ .I1> . 1i - , a_
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UNVEHEATER
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Y -- r INSURANCE COVERAGE
I have a current liability insurance po icy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 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:lam 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 Q 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 t best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance it anent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ._
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 SIGNATURE
MPD MGF❑ JP JGF❑ LPGI❑ CORPORATION CP PARTNERSHIP❑#— LLC 0#
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
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