HomeMy WebLinkAboutG-14-989 . . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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41 ! MA DATE 414( ) 9 I PERMIT 4/�
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JOBSITEADDRESS) ,, F(,,LtkC2- ti f4" IOWNER'S NAME CML014 it e/, /1T)fil
GOWNER ADDRESS Q 411,94,44 4.0 44 cIAWGk,0611ny3'f D TEL >f --- )Xti`+--- FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIOJNAL ❑ RESIDENTIAL r-
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1. FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOOSTER
CONVERSION BURNER I —,
BOILER
COOK STOVE
DIRECT VENT HEATER i I i Ii
DRYER III
FIREPLACE
FRYOLATOR _ I I -- y i
FURNACE _ i, .
GENERATOR .. i' I i _ I
GRILLE
INFRARED HEATER
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LABORATORY COCKS i _ I
MAKEUP AIR UNIT __
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POOL HEATER
ROOM/SPACE HEATER --
ROOF TOP UNIT I
TEST f
UNIT HEATER j 4I
UNVENTED ROOM HEATER I
WATER HEATER It 1
OTHER i r I
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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 Q 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 El
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-,J:tf my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pert'-eyrrovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE#I 13417 I SI ..4, .RE
MP Q MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP EP LL ■: _
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COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Road
CITY Dennis STATE MA _ZIP 02638 TEL 508-385-1°nitA • 14
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net .t 4.0-
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