HomeMy WebLinkAboutBLDG-20-003981 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_ti CITY I.®�l-:v.3 __��,0.,.!tijt'�'1f1A ... 1 MA DATE I I'll .2 1) 1 PERMIT# AA' 1i a Ct) /
ti JOBSITEADDRESS i)'LCI41,1iccr ` l[ ') 'OWNER'S NAME I air!able'lt 1,[i,/Z,V VI 1
GOWNER ADDRESS [ .-s 40,1- 1 TEL I FAX; _ I
TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL iD RESIDENTIAL Li
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CLEARLY NEW:J RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES NO E�
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOOSTER Mir '111111= _i i I I l; . i
CONVERSION BURNER MUM 1. I am. -..
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DIRECT VENT HEATER I '' i'' -
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FRYOLATOR WOW MIX F---JillacMillirltaill.1.1..1,1111.1111
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY EJ OTHER TYPE INDEMNITY BOND 0
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 0 AGENT 1
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 t• : .est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian.- with all •- ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R.PETER CHECKOWAY I LICENSE#P 13417 I NATURE
MP i,J MGF Li JP IA JGF J LPGI® CORPORATION E#[4008 I PARTNERSHIP[3# 1 LLC®#[ 1
COMPANY NAME: BOURQUE HEATING&COOLING CO I ADDRESS[1199 PITCHERS WAY I
CITY HYANNIS I STATE FTATI ZIP 102601 ITEL{508-790-2887
FAX 508-771-9696 . 1 CELL 508-735-9993 !EMAIL info@bourqueheati andcooling.com
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