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HomeMy WebLinkAboutBLDG-23-005075 PF MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r=. 1-1=f-k �1 i CITY 'YARMOUTH I MA DATE (March 15,2023 'PERMIT# BLDG 23 005075 JOBSITE ADDRESS 140 DEBS HILL RD UNIT 3B I OWNER'S NAME (LOWENTHAL ARLINE TR G OWNER ADDRESS THE ARILINE LOWENTHAL TRUST 40 DEBS HILL RD UNIT 3B YARMOUTH PORT MA TEL I I 02675-2530 TYPE OR I OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: • INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF 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. 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 best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Ir checkoway I LICENSE# 113417 I SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG! El CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑#1 I COMPANY NAME: ICHECKOWAY ENTERPRISES ADDRESS. 111 scargo hill rd,11 SCARGO HILL RD CITY DENNIS STATE MA ZIP 102638 I TEL 15083851911 FAX I I CELL I I EMAIL Icheckentta�,comcast.net -.' ° MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s+asa s al t E1T1'vAtM T PORT r MA DATE 3/6/23 PERMIT#/$L -Z3r case)bj- JOBSITE AD E S 40 DEBS HILL RD,YPT a OWNER'S NAME `ARLENE LOWENTHAL AR bajAI L. DD ES SAME TEL FAX A 4dT1 E COMMERCIAL EDUCATIONAL RESIDENTIAL PRATT--;-- - CLEARLY NEW: !, RENOVATION: = REPLACEMENT: PLANS SUBMITTED: YES . NO APPLIANCES Z FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE �.. v ; DIRECT VENT HEATER . DRYER .. . . r ., . . FIREPLACE .. —_-FRYOLATOR FURNACE GENERATOR GRILLE 4 s INFRARED HEATER LABORATORY COCKS i MAKEUP AIR UNIT OVEN �. _. POOL HEATER , , ROOM/SPACE HEATER { ' II, ROOF TOP UNIT TEST s ...,UNIT HEATER �' . UNVENTED ROOM HEATER g WATER HEATER OTHER , INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' OTHER TYPE INDEMNITY BOND I ; 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 ; ENT 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 - of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al P • provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 S alter MP . MGF ,' JP JGF LPGI CORPORATION # PARTNERSHIP -# LLC '#' COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd CITY Dennis STATE MA ZIP 02638 sTEL 508-385-1911 FAX 508-385-6858 CELL 508-735-9993 `EMAIL checkent@comcast.net