HomeMy WebLinkAboutBLDG-17-0015387 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY South Yarmouth MA DATE 9-24-16 PERMIT#
JOBSITE ADDRESS 22 Edgewater Dr, S Yarmouth OWNER'S NAME Steve Pezella
OWNER ADDRESS 16 Adams Farm Rd, Shrewsbury 01545 TEL 508-981-4802 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL !]
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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 1
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _
OVEN _
POOL HEATER _
ROOM/SPACE HEATER
ROOF TOP UNIT •
TEST
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 i i 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 I
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 the,6est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wjth Pe ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / a
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 `NATURE
MP MGF JP Ell JGF LPG' • CORPORATION Q# PARTNERSHIP LLC #
COMPANY NAME: Checkoway Enterprises i ADDRESS' 11 Scargo Hill Rd
CITY Dennis I STATE MA ZIP 02638 ,TEL 508-385-1911
FAX 508-385-6858 CELL' 735-9993EMAIL[checkent@comcast.net