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HomeMy WebLinkAboutBLDP&G-001551 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK :1111,� ` CITY W YARMOUTH MA DATE 9/17/19 PERMIT# etc P -tS O/✓s 1 aull� JOBSITE ADDRESS 16 CIRCUIT RD EAST,W Y I OWNER'S NAME WALLY HOUDE 1 POWNER ADDRESS 09 NORTH ST,STONEHAM _ TEL 617-775-0619 ]FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 0 PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES rj NOT FIXTURES 7 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 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 v 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 e est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P rti t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 RE MP ' JP CORPORATION # PARTNERSHIP # 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 _1 Vie' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY W YARMOUTH MA DATE 9/17/19 PERMIT#oleo() "aQ/- S 1 �Yt.�O 1 �_GGG_ JOBSITE ADDRESS 16 CIRCUIT RD EAST,W Y OWNER'S NAME WALLY HOUDE _ GOWNER ADDRESS 109 NORTH ST,STONEHAM TEL 617-775-0619 FAX w TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: i 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 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 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 i OTHER TYPE INDEMNITY BOND fl 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 GENT 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 e of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Perti rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� PLUMBER-GASFITTER NAME[R Peter Checkoway ,LICENSE# 13417 URE MP MGF 0 JP ` JGF LPG!I_, CORPORATION # PARTNERSHIP1J#i �_/ ]LLC L # 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