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HomeMy WebLinkAboutBLDG-23-000237 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vol CITY 'YARMOUTH I MA DATE (July 14,2022 I PERMIT# BLDG-23-000237 JOBSITE ADDRESS 3 OAK GLEN VILLAGE OWNER'S NAME YOUNG DAVID G OWNER ADDRESS LOUNG SANDRA 18 WESTVIEW DR MANSFIELD MA 02048 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 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 Ircheckoway I LICENSE# 13417 SIGNATURE MP©MGF❑JP❑ JGF❑ LPG'❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ICHECKOWAY ENTERPRISES I ADDRESS. 111 scargo hill rd,11 SCARGO HILL RD CITY 'DENNIS I STATE MA ZIP I02638 I TEL I5083851911 _FAX CELL I I EMAIL Icheckentecomcastnet S310N M3IARI NVId #J L'N d $ :33d El Ea .IL 2d 3H1 SV S3A2l3S NOLLVOIlddV SRL oN saA S3lON N01103dSNI 1VNId AlNO 3Sfl b01.03dSNI 2IO 13OVd SIHl S310N NO1103dSNI SVO HOflO J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK fil " I,•,� CITY YARMOUTHPORT MA DATE 17111/22 PERMIT # JOBSITE ADDRESS 3 OAK GLEN, KINGSWAY OWNER'S NAME DAVID YOUNG GOWNER ADDRESS SAME TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: l REPLACEMENT: PLANS SUBMITTED: YESD NO APPLIANCES Z FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 it BOILER BOOSTER _ CONVERSION BURNER COOK STOVE 1 _.. DIRECT VENT HEATER --I DRYER FIREPLACE FRYOLATOR FURNACE 1_ GENERATOR i GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN l� POOL HEATER i 4 ROOM / SPACE HEATER ____ 4- ROOF TOP UNIT TEST ,.,,, UNIT HEATER UNVENTED ROOM HEATER i WATER HEATER OTHER _- — 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 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 ,ie,tiest of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER-GASFITTER NAME R Peter Checkoway „..jLICENSE # 13417 SI RE MP MGF JP JGF LPGI Li CORPORATION El#F. PARTNERSHIP . #{ 1 LLC -1# COMPANY NAME: Checkoway Enterprises rises ` ADDRESS , 11 Scargo Hill Rd , CITY Dennis STATE 54A ZIP 02638 TEL 508 3385-1911 FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net