HomeMy WebLinkAboutBLDG-15-000508 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESSIa7 /EOM Oft ya.ct VI.'/. IOWNER'S NAME ITor\ fin)P:40 KC 1
GOWNER ADDRESS c5h _ ITEL fl/- YYfgr IFAX _
TYPE OR OCCUPANCY TYPE COMMERCIAL❑/ i,- DUCATIONAL 0 RESIDENTIAL21
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CLEARLY NEW ' RENOVATION:❑ REPLACE ESI . PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 I , 13 14
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CONVERSION BURNER 1 1i l
COOK STOVE i
DIRECT VENT HEATER I
DRYER I
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GENERATOR I 1 I
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MAKEUP AIR UNITi i
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t uiw: .� q INSURANCE COVERAGE
I h. ey.. /a r. e 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 a OTHER TYPE INDEMNITY ❑ BOND ❑
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 0 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 tot t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al Pe t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 GNATURE
MP Q MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME: Checkoway Enterprises •-•ADDRESS 11 Scargo Hill Road
CITY Dennis I STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 I CELL 508-735-9993 EMAIL checkent@comcast.net
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