Loading...
HomeMy WebLinkAboutG-14-277 .. ._ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - -.- `, . 1, CITY Yarmouth /MA DATE 09/04/13 PERMIT# (7/7 —0777 u JOBSITE ADDRESS 6 Cypress Point Way(South Yarmouth) M#91/P#74 OWNERS NAME:Brouchu GOWNER ADDRESS SAMETEL 508394-0324 FAX TYPE OR OCCUPANCY TYPE COMMERCIALEDUCATIONALRESIDENTIAL PRINT ❑ 0 CLEARLY NEW:0 RENOVATION: 0 REPLACEMENT: ® PLANS SUBMITTED: YES 0 NO❑ I APPLIANCES 7 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 7 NAtE GENERATOR GRILLE INFRARED HEA ftR LABORATORY COCKS TREOTATFICRIT OVEN POOL HEATER •• ROOM ! SPACE HEATER , ROOF FOP UNI f IESf - UNIT HEATER AcutPIkD/e l0, 9 UNVENTED ROOM • • r"' BY. WATER H ' A: O 1 Pil ' '0 . ! �m.•p• 1Ma INSURANCECOVERAGI I have • ® t,; ,u.•f t"Zt,"Z. --. policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES © NO El I IF YO _:-"'a— YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ... - — .• .. .-.. . LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY 0 BOND 0 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 mformabon I have submitted or entered regarding this application are true and accu . - • : • t of m. • 'ge an• I . all plumbing work and installations performed under the permit issued for this application will be In compliance with a -=rtin, provision Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME:James Pazakis LICENSE#PL-15030-M SI •TURE MP ® MGF❑ 'JP 0 JGF ❑'LPG! 0 CORPORATION ® #2803 •• •TNERSHI' ❑# , LLC❑# COMPANY NAME Hall Plumbing & Heating, Inc, ADDRESS 447 Old Chatham Road CITYSoulh Dennis STATE. MA ZIP 02660 TEL 508-385-9127 FAX 508-385-6604 CELL EMAIL HallTechnician@comcastnet I J ' ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No. ' THIS APPLICATION SERVES AS THE PERMIT 0 . 0 - ' • { FEE: $ PERMR# . • PLAN REVIEW NOTES " i F t A ,. n f .. % . . ...... • • � 1, r