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HomeMy WebLinkAboutBLDP&G-18-005200 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Fir_ t mot, CITY YARMOUTHPORT MA DATE 3 15 18 PERMIT#i —16' ��=� C JOBSITE ADDRESS 56 CANTERBURY RD,YPT OWNER'S NAME BERNIE NUGENT OWNER ADDRESS SAME TEL 508-362-2729 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES 1 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 I 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 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 at 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 Teti provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 �SIGNAT RE MP JP CORPORATION # PARTNERSHIP # # 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V---=7) CITY YARMOUTHPORT MA DATE 3-15-18 PERMIT# {/1'7)/ l r-cUJ 116. JOBSITE ADDRESS 56 CANTERBURY RD,YPT OWNER'S NAME BERNIE NUGENT GOWNER ADDRESS SAME TEL 508-362-2729 FAX 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/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 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 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 th est'of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with a I Pe ent-provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 SIGN URE MP ' MGF JP JGF LPG' 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 chedcent@comcastnet