HomeMy WebLinkAboutBLDG-16-006864 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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-,"'iif=-) CITY r eit/.- y,� u j MA DATE' 6/q , PERMIT# MID"' /lv`a763 9'
JOBSITE ADDRESS L/J Wt 0UQ l3 &ILO .wy OWNER'S NAME Nt8fle 676045 77—
GOWNER ADDRESS TEL IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL E RESIDENTIAL''
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CLEARLY NEW:J RENOVATION:[ I REPLACEMENT:❑ PLANS SUBMITTED: YES El NOD
APPLIANCES 1 FLOORS--, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER Ll It _. 1
BOOSTER _ - iL ._ 1' .l
CONVERSION BURNER
COOK STOVE y ,� = t
DIRECT VENT HEATER 1( 11- l —1(
DRYER il
FIREPLACE -- _ _ _ _�-.
FRYOLATOR -_
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FURNACE -_
GENERATOR -
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GRILLE /
INFRARED HEATER j II._ —1
LABORATORY COCKS _ i
MAKEUP AIR UNIT II . --'
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT �, „--
TEST 1 li
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UNIT HEATER fir_ -
UNVENTED ROOM HEATER I
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WATER HEATER_ —
OTHER
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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 NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY , OTHER TYPE INDEMNITY BOND 11
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 L 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 to the f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe 'n rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 TURE
MP Q MGF( JP I I JGF LPGI CORPORATION❑# PARTNERSHIP❑# I LLC Q#
COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Road
CITY Dennis STATE LMA J ZIP 02638 ITEL 508-385-1911
FAX 508-385-6858 I CELL,508-735-9993 EMAIL!checkent@comcast.net
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