HomeMy WebLinkAboutG-14-1048 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,WMALes=?-IIffEC CITY en/.y/7/2-#1.40ta MA DATE OAy PERMIT if L//e kyc
JOBSITE ADDRESS gab retie oo k( 4y. 'OWNER'S NAME Y1M 621.4(Jy I
GOWNER ADDRESS I W,9-7141 144 larb4,0 ( OiJly7 TEL def- 7fq - FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL'
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:r7 PLANS SUBMITTED: YESES NO❑
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 ' 5 r 6 7 8 9 10 11 12 13 14
BOILER r 111 1 I r
BOOSTER I-1 —I I—I( I111.
CONVERSION BURNER L_11 II { —I (l 1 I I
COOK STOVE J �` —I _ — } I
DIRECT VENT HEATER If
DRYER ISI I, , r---if IM
FIREPLACE I (
I Y— I
FRYOLATOR I 11 L. —I. ! I(—
FURNACE
GENERATOR1 11
GRILLEI Ii —II I I1
11� —1 I-1
INFRARED HEATER I-11 l - —1--11 ISI I I
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LABORATORY COCKS ' I I I, il
MAKEUP AIR UNIT ,�11 �I Irt I i, I I I
OVEN 1�1—ii (-14 I, I I_____ L ..
POOL HEATER - I- L II i
ROOM/SPACE HEATER —1F-1 1--(—�I�—I I it ( _ F--
ROOF TOP UNIT II ill 1 TEST � 11 ii.__ .. (- 1 1 1 i1-
UNIT HEATER (1-1. I 1 MISI
UNVENTED ROOM HEATER 1 —i f—{
WATER HEATER . ! (_ (_ --(. - I
OTHER --- I .1—t-i 7 T (a. } p ?
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. h.142aust{�7(U
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW BY-----C
LIABILITY INSURANCE POLICY 10 OTHER TYPE INDEMNITY p BOND 0 ,cp, d/
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 0
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 th t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi all •ert'the,
- provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 -
i• " ATURE
MP Q MGF❑ JP❑ JGF❑ LPG'❑ CORPORATION❑# PARTNERSHIP❑# 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
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