HomeMy WebLinkAboutBldg-19-006838 ' at. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSIT ADDRESS 5O I�,n O G I 1 l OWNER'S NAME }4ir7C1 W C11 I
GOWNER ADDRESS } ,vlli P i TEg77 f ,3E .640 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D, RESIDENTIAL V
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CLEARLY NEW:0 RENOVATION:ID REPLACEMENT:L✓ PLANS SUBMITTED: YES D NO
APPLIANCES 1 FLOORS—• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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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 0 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
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 El 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 t• = of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in complia .-with all •- ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R.PETER CHECKOWAY `LICENSE#1 13417 je NATURE
MP 0 MGF Q JP 0 JGF❑ LPGI CORPORATION 0# 4008 I PARTNERSHIP DIMES. LLC❑# 1
COMPANY NAME: BOURQUE HEATING&COOLING CO I ADDRESS 1199 PITCHERS WAY
CITY HYANNIS 1 STATE MA I ZIP I02601 ITEL 508-790-2887
FAX 508-771-9696 CELL 508-735-9993 'EMAIL info bourqueheatingandcooling.com
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# ✓ j
PLAN REVIEW NOTES FP/11/9 4-jc