HomeMy WebLinkAboutBLDG-17-002066 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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: `Ii-- CITY t� rav,,r�, fi . _ 1 MA DATE /0/J N4, I PERMIT#
r JOBSITE ADDRESS 18 Ptkt VDAre--- 1OWNER'S NAME d LA 1 r P Z..K 1
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TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ID RESIDENTIAL Er....-....-
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CLEARLY NEW:LJ RENOVATION:Q REPLACEMENT:I� PLANS SUBMITTED: YES D NOD
APPLIANCES I FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER li y _ ii (, 1.: _ . _°I J I
BOOSTER L a 9 .1:._._ ;`-i_._ �I— 1 _
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LABORATORY COCKS 1_ _ 1__, .I . ' E _ ,...._1 7-1
MAKEUP AIR UNIT
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ROOM/SPACE HEATER =MIN O Mt IMME I Mr r (I I,
ROOF TOP UNIT _ a _ ..1:�' MN all 1 MrC_...- h_I
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UNIT HEATER N 1:1E- 7. I-1.1 I (I. ' ------IL. .. , < 11 I
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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 0 NO ID
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY BOND Li
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 LI AGENT Li
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 t. _ .est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliant-with all '- ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R.PETER CHECKOWAY l LICENSE#1 13417 I de NATURE
MP LJ MGF El JP U JGF D LPGI® CORPORATION E# 4008 I PARTNERSHIP LI# I LLC,J#
COMPANY NAME: BOURQUE HEATING&COOLING CO I ADDRESS L1199 PITCHERS WAY
CITY t HYANNIS I STATE MA !ZIP!02601 ITEL 508-790-2887
FAX 508-771-9696 ' I CELL 508-735-9993 EMAIL info@bourqueheatingandcooling.com 1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ _ PERMIT#
PLAN REVIEW NOTES