HomeMy WebLinkAboutBLDG-18-004511 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-e, r CITY 5okyrin J c.f rnou MA DATE Z—Z 4 PERMIT#/'/4fJ'—/r"dd 9,47/
JOBSITE ADDRESS /O }} $ View )lit- OWNER'S NAME I igJ f J Gay/e
GOWNER ADDRESS goGy- TEL1 399'Cff5 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL,2
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CLEARLY NEW: RENOVATION:El REPLACEMENT:, PLANS SUBMITTED: YES L I N011
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 ' 7 8 9 10 11 12 13 14
BOILER _l—JL ir-T. !j
BOOSTER _ ._[ _ _ ._I _ IL_ _ AL _ _
CONVERSION BURNER -7
COOK STOVE I ___' _,,,,,,1
• 1
DIRECT VENT HEATER ir
DRYER - 1 _ __
FIREPLACE __ I , i _
FRYOLATOR _ _
FURNACE
GENERATOR I —ix
GRILLE �l�._ii 1 ___ _ _l
INFRARED HEATER
LABORATORY COCKS I.__ _ ..
MAKEUP AIR UNIT —11 -" y(
OVEN —
1, __
POOL HEATER
1 _ i
ROOM/SPACE HEATER a�_ _JL J� —JL.�. 1i
ROOF TOP UNIT IF— —1, —IF i—IF —ii J
TEST _ a l
UNIT HEATER !
UNVENTED ROOM HEATER
WATER HEATER 7(
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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 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 Li BOND 0
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.j 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 be my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P e ()vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway I LICENSE# 13417 S)PffriURE
MPH MGF L. JP❑ JGF❑ LPGI 0 CORPORATION # PARTNERSHIP❑#( LLC L#
COMPANY NAME: Checkoway Enterprises ADDRESS L11 Scargo Hill Road _
CITY Dennis STATELMA ZIP 02638 - lTEL 508-385-1911
FAX 508-385-6858 CELL,508-735-9993 EMAIL checkent@comcast.net
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