HomeMy WebLinkAboutBLDG-17-000849 MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
•
n=ci
CITY West Yarmouth MA DATE 18/1/16 I PERMIT# 0.16/6—/7-etV
JOBSITE ADDRESS 20 Lewis Bay Rd,WY OWNER'S NAME Frank Pandolfo
GOWNER ADDRESS 6 Buckman Dr,Burlington 01803 ]TEL[617-966-4456 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 7 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:' REPLACEMENT: + PLANS SUBMITTED:YES NO
APPLIANCES 1 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 TO P UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER r-
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 + 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:r1 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 r�4y of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with at Pemvision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway I LICENSE#.13417
MP + MGF❑ JP JGF LPGI 11 CORPORATION❑#r I PARTNERSHIP❑# LLC #
COMPANY NAME:Checkoway Enterprises —I ADDRESS 11 Scargo Hill Rd j
CITY Dennis —I STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-386-6858 CELL[B-735-9993 JEMAILI cteckent@comcast.net -- -
Lv '