HomeMy WebLinkAboutBLDG-19-003687 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ViV,tkig", CITY 1 WEST YARMOUTH MA DATE 12/13/18 PERMIT#/9/./��4�/-Ct io' '7
JOBSITE ADDRESS 98 CLEARBROOK RD,W Y OWNER'S NAME JOSEPH LANG
OWNER ADDRESS SAME
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— TEL 508-737-5028 JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL — RESIDENTIAL
PRINT
CLEARLY NEW: i RENOVATION:[- REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-4 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 1
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 i 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 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 i best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance al 'Went provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway I LICENSE# 13417 NATURE
MP / MGF JP JGF LPG! CORPORATION Il#1 PARTNERSHIP # LLC 0#
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COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 0 385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net
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