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HomeMy WebLinkAboutBLDG-23-001524 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK fl ;m CITY YARMOUTH MA DATE September 22,202 PERMIT# BLDG 23 001524 JOBSITE ADDRESS 875 GREAT ISLAND RD OWNER'S NAME CUSHMAN CLARE G OWNER ADDRESS 4717 ESSEX AVE CHEVY CHASE MD 20815 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO ❑ FIXTURES 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 FIREPLACE FRYOLATOR FURNACE GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT h TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 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. 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME r checkoway LICENSE# 13417 SIGNATURE MP© MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ADDRESS. 11 scarqo hill rd, CITY dennis STATE MA ZIP 02638 TEL FAX CELL EMAIL S310N M31A321 NVId #111N213d $:33d ❑ ❑ .II1 3d 3H1 SY S3A2i3S NOI1Y3Ilddtl SIHJ oN sOA S310N NO1103dSNI 1VNId VINO 3Sfl 210103dSNI 2i0d 39Vd SIH1 S310N NO1103dSNI SVO HJf1021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1—Mi7=-1 •�" � CITY WEST YUARMOUTH J MA DATE19/22/2022PERMIT # E �-- 1 2 `l JOBSITE ADDRESS rim GREAT ISLAND RD, WY OWNER'S NAME CLARE CUSHMAN GOWNER ADDRESS V___., , 7 7)- - x ( ✓ 'l n: ✓Y`f : ` - TE i — '- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL " RESIDENTIAL PRINT CLEARLY NEW: i RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS-4 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 i •.sec FIREPLACE FRYOLATOR FURNACE GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKSI MAKEUP AIR UNIT OVEN _ __ — ~ POOL HEATER _ u ROOM / SPACE HEATER ROOF TOP UNIT TEST 1 _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ OTHER - -. - INSURANCE COVERAGE I have a current liabiliiinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ILi NO C I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 a best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with efinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME R Peter Checkoway LICENSE # 13417 S NArTURE MP E MGF L., JP JGF LPGI CORPORATION # PARTNERSHIP .,# LLC # COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd CITY Dennis STATE MA ZIP 02638 -------- TEL 508-3 • FAX 805 385-6858 CELL 508 735-9993 EMAIL checkent@comcast.net _ � w�w . . SEP 2 2 2022 i BUILOI [ E 1:&s_1/1Elitg-T BY __ _