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HomeMy WebLinkAboutBLDG-23-000188 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE 'July 12,2022 I PERMIT# BLDG-23-000188 "T JOBSITE ADDRESS 1692 ROUTE 6A I OWNER'S NAME DONOVAN RICHARD M G OWNER ADDRESS DONOVAN KATHLEEN R 8 BLUEBERRY HILL DEDHAM MA 02026 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 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 1 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY El 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 rcheckoway LICENSE# 13417 SIGNATURE MP©MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑#L PARTNERSHIP ❑# LLC❑# COMPANY NAME: CHECKOWAY ENTERPRISES ADDRESS. 11 scargo hill rd,11 SCARGO HILL RD CITY DENNIS STATE MA ZIP[02638 TEL 5083851911 FAX CELL EMAIL checkentAcomcast.net • S310N M3IA38 NYld #JIWZl3d $:33d ❑ ❑ 111183d 3H1 SV S3A83S N011VOIlddv SIHl oN saA S310N NOI103dSNI lYNI3 AlNO 3Sl 210103dSNI 803 3OVd SIHI S310N N01103dSNI S11J HJf1021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4-pig = CITY 1 YARMOUTHPORT MA DATE 7/7/22 PERMIT # G-3 c / 3 JOBSITE ADDRESS( 692 ROUTE 6A, YPT JOWNER'S NAME RICHARD DONOVAN GOWNER ADDRESS SAME TEIJ 617-694-6415 1 FAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL i` I RESIDENTIAL; PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: 1 PLANS SUBMITTED: YES NO7-1 APPLIANCES -1 ••' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER MIME BOOSTER . __111111111 III_NIP _- CONVERSION BURNER ____1.11111 _MilliMICOOK STOVE 111111111111 _ DIRECT VENT HEATER M D" � ME GENERATOR ___I GRILLE -1. INFRARED HEATER IIIIIIIIIPIIIIIIIIIIIIIIIILABORATORY COCKS - MAIM Mil 1110111.. OVEN ___-_ MAKEUP AIR UNIT Milli 111111 POOL HEATER _______ ____ ROOM 1 SPACE HEATER _____________ ROOF TOP UNIT TEST _____ _ UNIT HEATER (! _ME — — UNVENTED ROOM HEATER __ _ WATER HEATER __._ II OTHER Till 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 i OTHER TYPE 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. CHECK ONE ONLY: OWNER 7 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 • • e best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi . rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Z //: - PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE # 13417 .IGNATURE MP v MGF JP JGF LPGI CORPORATION # PARTNERSHIP ru • LLC # 1 COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd 1 CITY Dennis STATE rMA ZIP 02638 TEL 508-385-1911 FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net 1