HomeMy WebLinkAboutBLDG-18-005333 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY MA DATE :f/�/// 0 PERMIT# Db/T '1
JOBSITE ADDRESS �
-- - OWNER'S NAME 4Yj4(i'm '� � f2- -'�1
GOWNER ADDRESS L J .CII 1 TEL'��s','?9g.-SL� ' Axi i
TYPE OR OCCUPANCY TYPE COMMERCIALLI EDUCATIONAL j RESIDENTIAL 2
PRINT CLEARLY NEW:D RENOVATION:® REPLACEMENT:[2/ PLANS SUBMITTED: YES LI NO'
APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOOSTER ` �i 'IM 1 # - I—
CONVERSION BURNER WIC IIIII, it ': AI. `
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DIRECT VENT HEATER L •_,_,., 1 t•I u;__ ... ' i
DRYER
FIREPLACE �. � = 1 + i
FRYOLATOR I I
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GENERATOR I
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=INFRARED HEATER =' nil
LABORATORY COCKS M 1.111111111 M. 111.11=111.1 ' 01111111, Awl!
MAKEUP AIR UNIT l i�� I
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POOL HEATER - ' ai :, :
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ROOROOFTOP UNIT I SPACE EATER B . I i :R
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UNIT HEATER � I�
UNVENTED ROOM HEATER ..1� I !I
WATER HEATER XI II _ ---______._...all___
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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
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY BOND U
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 j AGENT U
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. _ •est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian.- with all -- ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R.PETER CHECKOWAY I LICENSE#1 13417 I NATURE
MP U MGF U JP;D JGF Li LPG'Li CORPORATION # 4008 1 PARTNERSHIP D#I /LLC(P# .
COMPANY NAME:I BOURQUE HEATING&COOLING CO I ADDRESS 1199 PITCHERS WAY
CITY HYANNIS I STATE{ FAT FFATI ZIP 02601 ITEL i 508-790-2887 1
FAX 508-771-9696 . I CELLA508-735-9993 !EMAIL info@bourqueheatingandcooling.com
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES