HomeMy WebLinkAboutBLDG-17-001517 ` . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
%N CITY 1..r` 44A 1 __ m.-q. ,—1 MA DATE `(//(] / / (mil PERMIT# *VI?12,00 /
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JOBSITE ADDRESS 16 ( '1A A (-1iliftf a 1M OWNER'S NAME ( i t V t.0 / i
GOWNER ADDRESS [ � l 1 TEL ?7 1-31 3 -OU FAX
TYPE OR OCCUPANC TYPE COMMERCIAL 0 EDUCATIONAL D RESIDENTIAL ay-
PRINT
CLEARLY NEW: ' RENOVATION:® REPLACEMENT:Li PLANS SUBMITTED: YES U NOD
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOILER
BOOSTER i' � _;�
CONVERSION BURNER F I , , 1 ,I--in it -, , ,
COOK STOVE II
, -DIRECT VENT HEATER =i _I ;_
DRYER l I i. I_ i z r--W
FIREPLACE i '. ! i ;
FRYOLATOR
FURNACE 61 . ~_ i ■.II>•r3f �1 '€_.. lt.-._.
GENERATOR ' ``•-
GRILLE MI =1-4=1=___111111/5"INFRARED HEATER M
LABORATORY COCKS �� 1 ' I'
MAKEUP AIR UNIT II•Il{ `�': �1�1 =__ _` -
OVEN 1 I li I 'l. lU
POOL HEATER i I ..,.
ROOM I SPACE HEATER , �; 1111111 1 '
ROOF TOP UNIT 111111W1M1111111111111111111r INN 1 '
TEST _E W _, _ I'
UNIT HEATER UNVENTED ROOM HEATER 1�����1111. �_!��.�'�f�,� M
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WATER HEATER WWII=MIM;_ _ _
OTHER NM MINK am aii! -iwair= a
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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 U
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY D. BOND LI
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 U
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#1 13417 I NATURE
MP 0 MGF[l JP 1,11 JGF J LPGI® CORPORATION D# 4008 I PARTNERSHIP LJ#1 /LLC LJ# I
COMPANY NAME:,BOURQUE HEATING&COOLING CO I ADDRESS' 1199 PITCHERS WAY
CITY j HYANNIS 1 STATE MA I ZIP 102601 JTEL 508-790-2887
FAX 508-771-9696 ; I CELL[508-735-9993 IEMAIL info@bourqueheatingandcooling.com
I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
RP#' MS die Z-, f! 7/62$A Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
_ FEE: $ PERMIT#
PLAN REVIEW NOTES
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