HomeMy WebLinkAboutBLDP&G-20-003098 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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t CITY W YARMOUTH MA DATE 11/19/19 PERMIT 10:-/2/1` -Od
JOBSITE ADDRESS 1 RIG LANE,W Y OWNER'S NAME MARIANNA COSTA j
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL RESIDENTIAL 0
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES ri NO?l
FIXTURES 7 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM 1 _
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK _
TOILET _
URINAL _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
WATER PIPING
OTHER
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 1 OTHER TYPE 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.
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 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'S NAME R Peter Checkoway LICENSE# 13417 SIGNATURE
MP JP CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo Hill Rd
CITY Dennis j STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net
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F MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i6
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®"�i_= CITY W YARMOUTH MA DATE 11/19/19 _ PERMIT#/ �>ai d4-C Y 0
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JOBSITE ADDRESS 1 RIG LANE,W Y OWNER'S NAME MARIANNA COSTA
GOWNER ADDRESS I TEL IFAXL
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 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
DIRECT VENT HEATER
DRYER
FIREPLACE _
FRYOLATOR _
FURNACE _
GENERATOR _
GRILLE _
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER
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
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 j R Peter Checkoway LICENSE# 13417 SIGNATURE
MP i MGF ,_,1 JP;J JGF[. LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME: Checkoway Enterprises j ADDRESS 11 Scargo Hill Rd J
CITY Lpennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-38-5-6858 CELL 508-735-9993 EMAILEcheckent@comcast.net