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HomeMy WebLinkAboutBLDG-18-005091 \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7 Ni=• CITY L ai i,vt ipi MA DATE [A (PERMIT# i%t;O OW-j?/ JOBSITE ADDRESS bC ;) , ;)- i I OWNER'S NAME�'�Q CIA rA e C S d / i G OWNER ADDRESS 6 ' (SII-d t ;S I , E_k/A rift, 02_66 TEL j",�V8' f FAXi 1 TYPE OR OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL U RESIDENTIAL(E PRINT CLEARLY NEW:U RENOVATION:U REPLACEMENT: PLANS SUBMITTED: YES D N0 APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i J BOOSTER ; illt gig .. 1. XII um CONVERSION BURNER i ? iill COOK STOVE I MI IWO= 1 1 , DIRECT VENT HEATER .' ' I' 1 ! ,i DRYER 1 1 ; FIREPLACE "URRRUN l { :7`.1 i FURNACE iumm. iE I t GENERATOR -- ice_' I' '=E NGFILLE III=RARED HEATER M M.41111,_l� E LABORATORY COCKS UMW 'MMIIIIMMIMIMWS MAKEUP AIR UNIT MOMS MS `I V Imo'JIM IllitiMe ni , OVEN j , POOL HEATER ROOM I SPACE HEATER ViaLTAREME ! ---I -- iff----- , ROOF TOP UNIT 111111,1111111iw lam,'n am wim w �i i _ IK _ ,_ _ TEST W _? UNIT HEATER UNVENTED ROOM HEATER [� I M�WATER HEATER gm?- ;[ itriir i :` OTHER :� M ,W1 � ., ,, , , wig ,, . ___, 2 I , INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY (j OTHER TYPE INDEMNITY al BOND ID 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 0 AGENT LJ 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 complian.- with all •- ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME R.PETER CHECKOWAY 1 LICENSE#[13417 I NATURE MP I I MGF U JP U JGF IJ LPGI® CORPORATION 0# 4008 I PARTNERSHIP D# I LLC J# 1 COMPANY NAME: BOURQUE HEATING&COOLING CO I ADDRESS 1199 PITCHERS WAY CITY HYANNIS I STATE FICA—Al FICA—Al ZIP!02601 ITEL 1508-790-2887 FAX 508-771-9696 CELL 508-735-9993 !EMAIL info©bourqueheatingandcooling.com J 412 v1 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