HomeMy WebLinkAboutBLDP-18-005332 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL ® RESIDENTIAL V
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
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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 NO Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ® BOND Li
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,- ...t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complianh all P- t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R PETER CHECKOWAY LICENSE# 13417 " G TORE
MPQ JP❑ CORPORATION❑# 4008 PARTNERSHIP Olt LLC_#I i
COMPANY NAME BOURQUE HEATING&COOLING CO ADDRESS 1199 PITCHERS WAY 1
CITY HYANNIS 1 STATE MA I ZIP 02631 I TEL 508-790-2887
FAX 508-771-9696 1 CELL 508-735-9993 EMAIL info@bourgeheatingandcooling.com