HomeMy WebLinkAboutBLDG-19-003071 V 0 - 2. C)
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1,7,11— CITY W. y ►''r1 (442 MA DATE f1— 13-16 _1PERMIT#, ,
..... .......
JOBSITE ADDRESS /t GG roJn.-r( L 11/ OWNER'S NAME I GGindi 8/c&
GOWNER ADDRESS TEL! 77 J6 Zez tz(3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL Tr
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:Er PLANS SUBMITTED: YES❑ NO—__I
APPLIANCES 1 FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _-5-
BOOSTER
CONVERSION BURNER
COOK STOVE / _— ---
DIRECT VENT HEATER __JL _` i1 —111
DRYER —[ 11— 1
-FIREPLACE ..l. ii __L I!_
c— is m. _,._._ --- ---
FRYOLATOR = ---
___ _1;.J1 —
FURNACE �__ '._ 4 71V
GENERATOR _ _
GRILLE 1 _ II l —
INFRARED HEATER _
LABORATORY COCKS r -I(
MAKEUP AIR UNIT
L. 11
OVEN _—1 r
POOL HEATER I r
ROOM/SPACE HEATER ii
ROOF TOP UNIT _
TEST - - i
1
UNIT HEATER I It IL
UNVENTED ROOM HEATER —11
WATER HEATER �;`
OTHER [— �! I
J ..�INSURANCE COVERAGE l I 1 _
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO U
I IF YOU I CHECKED_YFS,PLFASE INDICATE THE_TYPE_OF COVFRAGE BY CHECKING THE APPROPRIATE-BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY f 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 ❑ ENT ❑
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 st fif my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with I Perti t ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 S URE
MP 0 MGF n JP❑ JGF 0 LPGI El CORPORATION Q# PARTNERSHIPLi#L LLC(l#
COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Road
CITY , Dennis STATE MA ZIP[02638 TEL 508-385-1911 1
FAX[508-385-6858 j CELL!508-735-9993 EMAIL checkent@comcast.net j