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HomeMy WebLinkAboutBLDG-22-007185 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK T CITY YARMOUTH MA DATE June 13,2022 PERMIT# BLDG-22-007185 1�s- JOBSITE ADDRESS 21 MAYFLOWER RD OWNER'S NAME Jason stabach G OWNER ADDRESS MA 02067 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 _ 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 ❑ 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 checkoway LICENSE# 13417 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: CHECKOWAY ENTERPRISES ADDRESS. 11 scarqo hill rd,11 SCARGO HILL RD CITY DENNIS STATE MA ZIP 02638 TEL 5083851911 FAX CELL EMAIL checkentcomcast.net S310N M31A3H NVId #11M3d $ 33d ❑ 111*Ed 3H1 SV S3A213S NOI1V3IlddV SIHI oN saA S310N NO1103dSNI 1VNId AINO 3sn a0133dSNI 210d 3EVd SIHI S31ON NO1103dSNI SHE HEl0H MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I4``t-=1f III xtrik_ ;- CITY WEST YARMOUTH MA DATE r6/6122 PERMIT # ! I d S JOBSITE ADDRESS 21 MAYFLOWER RD, W Y OWNER'S NAME I JASON STABACH GOWNER ADDRESS 1335 GRISWOLD RD, WEATHERSFIELD, CT 06109 TE''1I860-798-1573 FAX ____ _r, TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES j NOS 1 APPLIANCES Z FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER . ---c- . BOOSTER CONVERSION BURNER — COOK STOVE 1Aglaia- - _ DIRECT VENT HEATER — DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR i — — _ GRILLE r INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT OVEN _,.._ POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I1 OTHER 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 F OTHER TYPE INDEMNITY Li 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 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 t t be, of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with I ' tai'provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - / PLUMBER-GASFITTER NAME R Peter Checkoway 1 LICENSE #L 13417 SI ATURE MP i MGF I., JP JGF LPGI CORPORATION p# PARTNERSHIP,,# LLC 1 # COMPANY NAME: Checkoway Enterprises ADDRESSLaScargo Hill Rd CITY Dennis I STATE L MAC ZIP 02638 JTEL {508-385-1911 FAX 508-385-6858 1 CELLI 508-735-9993 JEMAIL checkent@comcast.net