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HomeMy WebLinkAboutBLDG-22-006774 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 18 CITY [YARMOUTH 1 MA DATE May 23,2022 PERMIT# BLDG-22-006774 / JOBSITE:ADDRESS 24 EMBASSY LN OWNER'S NAME Victor Dadras G OWNER ADDRESS 24 EMBASSY LN YARMOUTH PORT MA 02675-1521 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ID RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS—a 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 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 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 ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [;HECKOWAY ENTERPRISES ADDRESS. 11 scargo hill rd,11 SCARGO HILL RD CITY DENNIS STATE MA ZIP 02638 TEL 5083851911 FAX 1 CELL EMAIL checkent(!comcast.net S310N M3IA32J NVId #11Wa3d $ 33d ❑ ❑ 11M3d 3H1 SV S3A83S N011V3IlddV SIHI oN saA S310N NO1103dSNI IVNId AINO 3Sfl a0103dSNI 2JOd 30Vd SIHI S310N NO1103dSNI SVO HOfOa MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q,.1 • e CITY YARMOUTHPORT MA DATE 15119122 PERMIT # JOBSITE ADDRESS 24 EMBASSY LANE, YPT OWNER'S NAME VICTOR DADRAS CTOWNER ADDRESS 41-11 GLENWOOD SR, LITTLE NECK, NY TEL 917-693-2319 FAX1 TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESL NOn APPLIANCES -1 LOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER r CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR i�_-- -._ -_ -_ - FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN L POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST . . UNIT HEATER ji UNVENTED ROOM HEATER vamp WATER HEATER OTHER i -- '- INSURANCE COVERAGE I have a current liabilityinsurance 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-} AGENT SIGNVURE OF OWNER OR AGENT i I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to,� best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME [ Peter Checkoway LICENSE #r13417 TURE MP MGF E JP JGF r LPG! © CORPORATION # —I PARTNERSHIP®iC LLC -'# COMPANY NAME: Checkoway Enterprises ADDRESS 11 Scargo Hill Rd CITY Dennis STATE I MA ZIP 02638 TEL .508-385-1911 FAX 508 38385-68581 CELL 508-735-9993 EMAIL checkent@comcast.net 40'=• • • • • • • •