HomeMy WebLinkAboutBldg-19-006710 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
11- 4 CITY 1W YARMOUTH MA DATE 5-2219 J PERMIT# ,fib' /9- &7/'i
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JOBSITE ADDRESS 38 HUNTERS CIRCLE,W Y _ OWNER'S NAME I JOHN BIANCHERIA j
GOWNER ADDRESS 8 VENTURA AV,WORCESTER 01604 1 TEL 508-826-3252 1FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL_I EDUCATIONAL 0 RESIDENTIAL[
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CLEARLY NEW:[ - RENOVATION: ,,,1 REPLACEMENT:LI PLANS SUBMITTED: YES NO[
APPLIANCES 1 FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I - WEI -I I' _. . I - - - , L '
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BOOSTER 1 11 ? 1' i
CONVERSION BURNER 1'. 1'
COOK STOVE 1 I
DIRECT VENT HEATER ��iSM.,; Imo! ,M� IIMMIIIIIIIIIII an!NM'IMP
FIREPLACEDRYER 11111111' IIIMIirippnwEggi! , riwilmrip!
FRYOLATOR imitintf,iplmt inniin
FURNACE afimt 1
GENERATOR
GRILLE I II � I �INFRARED HEATER IMM IMMI I MN l ►MAKEUP AIR UNIT I I= 111! i I II! pinup
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POOL HEATER 1
1114 1 _1 1 p , -
LABORATORY COCKS maim
ROOM/SPACE HEATER
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UNVENTED ROOM HEATER Ljl -- llL;I1I WENN
WATER HEATER
OTHER' 11
RNVATER HEATER I
I COMBI BOILE MIIIIIMMUM
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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 ILI NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [] OTHER TYPE INDEMNITY f1 BOND LI
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 r1 AGENT U
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 est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Peter Checkoway LICENSE# 13417 IGNATURE
MP .f_J MGF J JP l JGF LPG![ CORPORATION'L..j#L _ I PARTNERSHIP #C „ C L:.. #I -_ __-
COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd 1
CITY Dennis - STATE( MA _I ZIP 02638 JTEL[5084851911 FAX r 608 385 6858 I CELL]508-735-9993 EMAIL checkent aecomcast net 1
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