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HomeMy WebLinkAboutG-13-729 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I CITY Yarmouth MA DATE 1/31/13 PERMIT# /9/9 7R? JOBSITE ADDRESS: 20 Quail Road (Yarmouth) M#14 P#35/PID#197, OWNER'S NAME: Joanne Freeman GOWNER ADDRESS r 108 Elinor Road Newton, MA 02461 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 131 ' PRINT CLEARLY NEW:0 RENOVATION: 0 REPLACEMENT: ® PLANS SUBMITTED: YES 0 NO O APPLIANCES 1 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- GRILLE INFRARED HEATER LABORATORY COCKS "MAIMIRTIWITT OVEN. POOL HEATER ACCEPTED 9% ROOM / SPACE HEATER `-3 ROOFTOP UNIT Bt5 ItSI UNIT HEATER UNVENTED ROOM HEATER • WATER HEATER OTHER INSURANCE COVERAGS I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES © NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [3] 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 0 AGENT 0 ' SIGNATURE OF OWNER OR AGENT • / I hereby certify that all of the details and information I have submitted or entered regarding this application are hue a . the best of m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance went provision of e , Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME:James Pazakis LICENSE#PL-15030-M ! .IG MP ® MGFD JP 0 JGF 0 LPG! 0 CORPORATION ® #2803 PARTNER • • • LLC 0# COMPANY , NAME Hall Plumbing 8 Heating. Inc. ADDRESS 447 Old Chatham Road CITY_South Dennis STATE MA ZIP 02660 TEL 508-385-9127 D IE lr7 is ii V L`+ FAX 508-385-6604 CELL EMAIL HallTechnidan(thcomcastnet - 4 201 O a�s (so-- Lulu)", 4y j ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLYFINAL INSPECTION NOTES Yes No' THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE $ PERMIT$ ' PLAN REVIEW NOTES . . i (l 'i