HomeMy WebLinkAboutBLDG-18-007398 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY W YARMOUTH MA DATE 6/21/18 PERMIT# PX' C / "c 1
JOBSITE ADDRESS 93 NORTH ST,WY OWNER'S NAME JACK FROUNJIAN
GOWNER ADDRESS 541 PLEASANT ST,MARLBORO TEL 857-294-9095 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 1 / -
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR f� j6r-
GRILLE
INFRARED HEATER rt
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 v 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 b 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 yie ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /•
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 SIGNAT
MP MGF JP JGF LPG! CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcastnet
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