Loading...
HomeMy WebLinkAboutBLDG-22-006109 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `-u CITY IYARMOUTH I MA DATE 'April 22,2022 I PERMIT# BLDG-22-006109 JOBSITE ADDRESS 126 GROVE ST I OWNER'S NAME Rebecca Coleman G OWNER ADDRESS MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 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 _ 1 DIRECT VENT HEATER DRYER _ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ ROOM/SPACE HEATER ROOF TOP UNIT TEST 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 0 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 R Peter Checkoway LICENSE# 13417 SIGNATURE MP©MGF❑JP 0 JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: R PETER CHECKOWAY ADDRESS. 11 SCARGO HILL RD, CITY DENNIS STATE MA ZIP'026382306 I TEL FAX I CELL EMAIL checkentWcomcast.net S310N M3IA32J Ndld #11M3d $ :33d ❑ ❑ 1.11412Ed 3H1 SV S3A2i3S NOIIVOIlddV SIHl oN seA S31ON N01103dSNI 1VNId AlNO 3Sf1 10103dSNI 21Od 39Vd SIH. S310N NOI103dSNI SVJ HOflO MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7� CITY WEST YARMOUTH MA DATE 4-19-2022 PERMIT # JOBSITE ADDRESS 26 GROVE ST, WY OWNER'S NAME REBECCA COLEMAN . - al GOWNER ADDRESS 12 FARFIELD DR, E SANDWICH TE 617-610-6616 /FAX i TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL -1 RESIDENTIAL PRINT CLEARLY NEW: ,j RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOL' APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I_ _ BOOSTER L. _ CONVERSION BURNER COOK STOVE 1 effikiikrair. ail., DIRECT VENT HEATER L. II DRYER r - - - -_ - - - - FIREPLACE FRYOLATOR - - FURNACE � _ _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS i MAKEUP AIR UNIT OVEN POOL HEATER 11 ROOM / SPACE HEATER i( ROOF TOP UNIT _ ...arm... TEST _- � `�UNIT HEATER UNVENTED ROOM HEATER -,--_ WATER HEATER OTHER e ,.,,. . ft INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ; v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY r' OTHER TYPE INDEMNITY BOND 1 j 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 AGENT 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 t est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe ' nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. :- , PLUMBER-GASFITTER NAME ' R Peter Checkoway I LICENSE #[13417 ATURE MP i MGF L, JP JGF LPGI CORPORATION 0# PARTNERSHIP Lij# JLLCLJ#1 Alaioarterwmossa. ....1 COMPANY NAME: Checkoway Enterprises : ADDRESS[11 Scargo Hill Rd CITY Dennis — STATE MAI ZIP 02638 TEL 508-385-1911 . I FAX 1 508-385-6858 i CELLIE8-735-9993 EMAIL checkent@comcast.net