HomeMy WebLinkAboutG-14-461 L-77 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY Yarmouth MA DATE 11/12/13 PERMIT# C(Li
JOBSITE ADDRESS 17 Bass River Road M# 70 / P# 99 OWNER'S NAME: Pazakis
GOWNER ADDRESS SAME TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NOD ,
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOOSTER ■.,,,....■.,,.
CONVERSION BURNER
COO TOVE
DRYER
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POOL HEATER
ROOM / SPACE HEATER
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UNVENTED ROOM HEATER
WATER HEATER I
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I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL Ch.142 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ® OTHER TYPE 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
CHECK ONE ONLY: OWNER AGENT 0
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and a- • • ebest of • owledge and that
all plumbing work and installations performed under the permit issued for this application will be in compliance withent provisio •f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME James Pazakis LICENSE#PL-15030-Mllip •• -.-
MP ® MGFD JP 0 JGF 0 LPG! 0 CORPORATION ® #2803 =•1-TNERS •• a • LLC 0#
COMPANY NAME Hall Plumbing & Heating. Inc. ADDRESS 447 Old Chatham Road
CITY South Dennis STATE MA ZIP 02660 TEL 508-385-9127
FAX 508-385-6604 CELL EMAIL HallTechnician(acomcast.net
1 ): ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
C I3/ B it�'y Yes No
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Q^� THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT# '
PLAN REVIEW NOTES _
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