HomeMy WebLinkAboutBLDG-19-004618 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
=t ), CITY JU`itin gat/4'M l i _-- MA DATE 115 U 1 19 1 PERMIT#A-P6 ?-1-V VW(
JOBSITE ADDRESS 11 Lo A 0-46 z rS im v v1 I- 112,b I OWNER'S NAME IA arr,
GOWNER ADDRESS ►00 6 0 160 ,`50 ( lM i-ti jTEU5bcb ,e' • 5 8 FAX' i
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIALD
CLEARLY NEW:D RENOVATION:El REPLACEMENT:[kr PLANS SUBMITTED: YES D NOD
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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 El NO U
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ED OTHER TYPE INDEMNITY U 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 CHECK ONE ONLY: OWNER 0 AGENT Li
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 complian with all e ' ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I R.PETER CHECKOWAY I LICENSE#1 13417
NATURE
MP Li MGF 0 JP 0 JGF® LPG!0 CORPORATION 0#l 4008 PARTNERSHIP 10# i LLC j#1 I
COMPANY NAME:BOURQUE HEATING&COOLING CO i ADDRESS y 1199 PITCHERS WAY
CITY I HYANNIS STATE MA I ZIP I02601 ITEL I 508-790-2887 i
FAX I 508-771-9696 I CELLI 508-735-9993
IEMAILI info@bourquehealingandcooling.com
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