HomeMy WebLinkAboutG-14-998 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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VIV -� CITY (A . Yfc2 nd.4}?} I MA DATE is Iy J PERMIT#n
JOBSITE ADDRESS y(J f V r45,5, 1V Vv,Y 'OWNER'S NAME (45- VE S/AV ('
GOWNER ADDRESS is - ITEL 97g-831-- y3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIAL2r
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CLEARLY NEW:E:1 , RENOVATIONS REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOOSTER I I-1
CONVERSION BURNER I
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DIRECT VENT HEATER I
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FURNACE FIREPLACE 110114:1,141,4
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FRYOLATOR �GENERATORGRILLE —I I
INFRARED HEATER Ng
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LABORATORY COCKS I I itiI
MAKEUP AIR UNIT I ! P
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POOL HEATER I I , ligROOMISPACEHEATER I I1 IROOF TOP UNIT I 1TEST I iIUNIT HEATER 1 i3 IUNVENTED ROOM HEATERWATER HEATER . rOTHER ��( 1 I
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INSURANCE COVERAGE 11 ti 2 COI'
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG i.Ch.142 YES BY ' ''' ili
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811, 151 NO
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I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO
LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY ❑ e IND y
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 •: of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Perti, rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 orf ATURE
MP Q MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP DI LLC at
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