HomeMy WebLinkAboutBLDG-20-004878 /'1 pi/V 14- Z.,lc) Z
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY S.YARMOUTH MA DATE 2-27-20 PERMIT# b ' � 7
JOBSITE ADDRESS 1 SPRUCE ST OWNER'S NAME BRENDA SMITH
OWNER ADDRESS i SAME TEL1860-202-6744 1FAXF 7
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z 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
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 AGE T
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 be of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with ertine rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4(NATURE
PLUMBER-GASFITTER NAME R Peter Checkoway .1 LICENSE# 13417
MP MGF T JP JGF LPGI CORPORATION-1# PARTNERSHIP # LLC #
COMPANY NAME: Checkoway Enterprises ADDRESS Ll1 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