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HomeMy WebLinkAboutBLDG-22-004560 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH I MA DATE [February 16,2022 PERMIT# BLDG-22-004560 JOBSITE ADDRESS 3 OAK GLEN VILLAGE OWNER'S NAME YOUNG DAVID G OWNER ADDRESS YOUNG SANDRA 18 WESTVIEW DR MANSFIELD MA 02048 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:❑ 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 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 0 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 IR Peter Checkoway I LICENSE# 113417 SIGNATURE MP 0 MGF❑JP 0 JGF❑ LPG( 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0#I COMPANY NAME: IR PETER CHECKOWAY I ADDRESS, 111 SCARGO HILL RD, CITY DENNIS (STATE MA ZIP I026382306 I TEL I FAX 1 1 CELL 1 1 EMAIL Icheckent(Ta.comcast.net 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 -- 1k21 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK *C1 CITY YARMOUTHPORT y MA DATE LE.22 PERMIT # JOBSITE ADDRESS LEAK GLEN OWNER'S NAME ! DAVID YOUNG 1 GOWNER ADDRESS 18 WESTVIEW DR, MANSFIELD JTELJFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL '� RESIDENTIAL i� PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES -1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER lr I CONVERSION BURNER II _ 1 '� COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATORIM I _ FURNACE ' - Wallill 1111110111 GENERATOR GRILLE l INFRARED HEATER III LABORATORY COCKS ! MITI" Ili MAKEUP AIR UNIT J , - --'....... lig! WIMP OVEN POOL HEATER ROOM / SPACE HEATER _ _i ROOF TOP UNIT !) _ I TESTM UNIT HEATER UNVENTED ROOM HEATER _ WATER HEATER i OTHER I ill . I ME '".- III= INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES i 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 ED 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 th st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — /-;./rli PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE # 13417 024ATURE MP v MGF JP ,,i JGF [ LPG' CORPORATION 0# -1 PARTNERSHIP(❑#L. LLC ,# COMPANY NAME: Checkoway Enterprises 1 ADDRESS blsargo Hill Rd CITY Dennis 4 STATE MA 1ZIPtO2638 ITEL 508-385-1911 FAX 508-385-6858 CELL 508-735-9993 IEMAILE checkent@comcast.net