HomeMy WebLinkAboutBLDG-16-004584 l (5yj ow
_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS-FITTING WORK
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MVO',V`,i� PERMIT# /✓OAT/b �" CITY �—e5 f— �yNr.^t�+�'1 MA DATE[ z//$f j6
JOBSITE ADDRESS Z/2 v"1 ,rd. rq-h Dc—e, OWNER'S NAME Cotee CS$c4.1,'ct 1
G OWNER ADDRESS 3 415 rvty,
55,i-5cA at) Iv.Oci6 11w/e'+ /n TEL IFAX
TYPE OR Ci OCCUPANCY TYPE COMMERCIALd EDUCATIONAL E RESIDENTIAL ii
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:Z. PLANS SUBMITTED: YESLJ NO❑
APPLIANCES 1 FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER J! --
CONVERSION BURNER
COOK STOVE ( t
DIRECT VENT HEATER 11-11aL
DRYER .
FIREPLACE FRYOLATOR
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FURNACE 3 --IF-
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GENERATOR
_GRILLE i __ -I
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
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OVEN ,[
POOL HEATER a iL._ _ __,rj
ROOM/SPACE HEATER �L"
ROOF TOP UNIT _
TEST
UNIT HEATER —ir
UNVENTED ROOM HEATER
WATER HEATER
OTHER i __jj
1 _..__-- _ __ - _ .-_______� i� 11
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
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 i 1 AGENT 0
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 t - .=.t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe . -r provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Z. Peter Checkoway LICENSE# 13417 .Y ATURE
MP 0 MGF n JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑#L J LC❑#
COMPANY NAME: Checkoway Enterprises I ADDRESS I 11 Scargo Hill Road
CITY 1 Dennis I
STATE MA ZIP 02638 ITEL 508-385-1911
FAX B08-385-6858 I CELL, 508-735-9993 EMAIL checkent@comcast.net
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