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Home My WebLink AboutBLDG-22-004720 :i. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =EFebruary BLDG 22-004720 CITY YARMOUTH 1 MA DATE 25,2022 PERMIT# sV "z JOBSITE ADDRESS 54 FENWAY OWNER'S NAME Michael Langton G OWNER ADDRESS 54 FENWAY SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT El 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 1 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 1 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 El 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 El MGF ❑ JP❑ JGF 0 LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: R PETER CHECKOWAY ADDRESS. 11 SCARGO HILL RD, CITY DENNIS STATE MA ZIP 026382306 TEL FAX 7 CELL EMAIL checkerta(u)comcast.net S310N M31A32i NVld #11W213d $:33d ❑ 0 111N213d 3H1 SV S3A2J3S NOI1V0IlddV SIH1 oN seA S310N N01103dSNI MU AINO 3Sfl 2J0103dSNI 2lOd 30Vd SIH1 S310N N01103dSNI SV0 H0l021 owimmor MASSACHUSETTS SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK z PERMIT 1-)2u Cf T'( 1 a �r��+� MA DATE �� ZZ — c JOBSITE ADDRESS 5 `1 Fen (.1 - OWNER'S NAME C`-) c h cz e L• a .15/ f-cn OWNER ADDRESS S a-r►� v �-I LI TutTEL (500 � `� FAX TYPE OROCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL I— RESIDENTIAL PRINT CLEARLY NEW: [if RENOVATION: ❑ REPLACEMEI\IT: ❑ PLANS SUBMITTED: ,�=YES ❑ NO ❑ APPLIANCES [ FLOORS-4 BSv1 1 2 3 '1 5 6 7 9 10 11 12 13 1 BOILER - BOOSTER CONVERSION BURNER - COOK STOVE DIRECT VENT HEATER DRYER, FIREPLACE FRYDLATOR �-' 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU. Ch. 142 YES Q NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F OTHER TYPE I1�8DEMNITY 1 BOND • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MaBsarhusetts General Laws, and that my signature on this permit application rives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 2 . Pe-te., c k e cIc C i LICENSE # 134 .? SIGNATURE MP ! ✓ MGF ❑ JP E JGF ❑ LPGI ❑ CORPORATION ❑ f PARTNERSHIP LLC ❑ # COMPANY NAME C e clCa c.. ai an ki' pr, k s ADDRESS if C cj u t4 I (.vf CITY Dann: S STATE h'' 1\" ZIP 0Z63 TE 9t 381 — / 7i( FAX CELL EMAIL C eCk.,o..n t- Com cas4- - nv` ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: v PERMIT PLAN REVIEW NOTES