HomeMy WebLinkAboutBLDP&G-20-006421 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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%.emu ._ CITY S YARMOUTH _ _ MA DATE 6/23/2020 PERMIT# i /1;)PG-c�i16`r
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JOBSITE ADDRESS 16 MIDSTREAM DR, S Y OWNER'S NAME[JEANNE GAGNON I
POWNER ADDRESS i SAME TEL 617-412-8629 'FAXr i
TYPE OR OCCUPANCY TYPE COMMERCIAL r - EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES 1 NO 71
FIXTURES-1 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB —II- _
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM _
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 i NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY { OTHER TYPE OF INDEMNITY ri 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 L.. AGENT
SIGNATURE OF OWNER OR AGENT •-7 _
I hereby certify that all of the details and infonnation I have submitted or entered regarding this application are true and accurate to therbest of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit all Pe ht provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i
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PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 ATURE
MP JP CORPORATION # PARTNERSHIP # - LLCLJ#[__
COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo Hill Rd
CITY Dennis STATE MA ZIP 02638 ' TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY S YARMOUTH MA DATE 6/23/2020 PERMIT# / /1' 'OO '/7
JOBSITE ADDRESS 16 MIDSTREAM DR, S Y _ OWNER'S NAME JEANNE GAGNON
GOWNER ADDRESS SAME 1 TEL 617-412-8629 1FAXL_ i I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL® RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: i 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/SPACE HEATER
ROOF TOP UNIT
TEST _
UNIT HEATER _
UNVENTED ROOM HEATER _
WATER HEATER 1 —1
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES v 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 t best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with I d ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 SI RE
MP LJ MGF JP JGF LPGI CORPORATION # PARTNERSHIP r'#r LLC #
COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 'EMAIL checkent@comcast,net