HomeMy WebLinkAboutBLDG-20-002223 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`r=;#_i, ' CITY ej r MA DATE ufflortimra PERMIT# &Ob"aD-65-call
JOBSITE ADDRESS 403/ /jl/(,k J ()C/ l9 II /k OWNER'S NAME r1)(u V 1 S i J(i Vt --p- i
GOWNER ADDRESS ,' A41-C. TEL y,y- 447y- 3I7o jFAXi 1
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:[3 RENOVATION:® REPLACEMENT:I1E PLANS SUBMITTED: YES Li NOar
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 I 9 10 l 11 It 12 13 14
BOILER 1 . I
BOOSTER ' _ _-_ Y f`
CONVERSION BURNER ' : ' JI L
COOK STOVE
DIRECT VENT HEATER r., 1-
il
DRYER n
FIREPLACE Y._.
FRYOLAT
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FURNACEOR it t
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GENERATOR IIIIII,NM:Milt lam' ��
GRILLE � -- I
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INFRARED HEATER �:
II
LABORATORY COCKS 1 i I 1 �'
MAKEUP AIR UNIT 9 f
OVEN I l - -_- ..
POOL HEATER _ .-. 1 f.. i
ROOM I SPACE HEATER I I
ROOF TOP UNIT
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TEST A — - 1, e- =— .1
UNIT HEATER i imilimillintionr 1_�_ _ N' - _.__
UNVENTED ROOM HEATER
WATER HEATER
OTHER
11.1
I J L L I. L 1' 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY [ 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 ID 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 est 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 I LICENSE#!13417 I NATURE
MP 0 MGF[3 JP 0 JGF El LPG' CORPORATION[3# 4008 I PARTNERSHIP[3# 6 LLC❑#
COMPANY NAME:,BOURQUE HEATING&COOLING CO I ADDRESS 1199 PITCHERS WAY d
CITY HYANNIS STATE MA IZIPl02601 ITEL 508-790-2887
FAX 508-771-9696 • I CELL.508-735-9993 EMAIL info@bourqueheatingandcooling.com I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /�,`�"' G�� / �/�
FEE: $ PERMIT#
PLAN REVIEW NOTES // �/ /?