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HomeMy WebLinkAboutBLDP&G-17-000360 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Yarmouthport MA DATE 7/13/16 PERMIT#eali/%—i 0 JOBSITE ADDRESS 36 Forest Gate(Kings Way) OWNER'S NAME Natalie Steinberg OWNER ADDRESS 346 Boylston St,Newton 02459 TEL 508-375-0615 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL -] RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO 1 FIXTURES 7 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/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 1 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 all 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 r t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I R Peter Checkoway LICENSE# , 13417 ATURE MP JP CORPORATION # PARTNERSHIP EJ# LLC[]# COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo Hill Rd r CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911 1 FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net • r` i .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Yarmouthport MA DATE 7/13/16 PERMIT#A-,9frf/-(l(J( • JOBSITE ADDRESS 36 Forest Gate (Kings Way) OWNER'S NAME Natalie Steinberg OWNER ADDRESS 346 Boylston St,Newton 02459 TEL 508 375 0615 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL n RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:[ REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES T 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 L.L.....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 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 •:.t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with2�ll Pe 'y provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `/ PLUMBER-GASFITTER NAME R Peter Checkoway I LICENSE# 13417 //f SI 00 I'E MP MGF h JP —I JGF I7 LPGI CORPORATION -1#! PARTNERSHIP # LLC Q#I COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911 FAX 508-385-6858 CELL 508-735-9991EMAIL c5-1-e—ckent@comcast.net Z-I/MCP .,�.� l .,�