HomeMy WebLinkAboutBLDG-20-006234 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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ARS CITY S YARMOUTH MA DATE 6/12/2020 PERMIT#/kL/26- d'•00 .1&y
JOBSITE ADDRESS 35 PARKERS NECK RD, S Y OWNER'S NAME WARREN ANDERSON
GOWNER ADDRESS 66 BOSTON AV, MEDFORD, MA 02155 TEd 781-738-8255 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ] RESIDENTIAL
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CLEARLY NEW:' RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER 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 [!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 n AGENT n
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 best-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 ineryt vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE# 13417 .itCP TURE
MP MGF JP JGF LPG' CORPORATION 0# PARTNERSHIP # LLC #
COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 7 5-08-385-6858 CELL 508-735-9993 EMAIL[checkent@comcast.net
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