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HomeMy WebLinkAboutG-13-575 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK - ---- L;' `�L • CITY , Yarmouth L/Srn o MA' DATE 12/05/12 PERMIT# Z7/3— 575- ig JOBSITE ADDRESS 1 Lis rive(West Yarmouth) ' M#39/P#21 OWNER'S NAME: Hannon G OWNER ADDRESS SAME TEL :FAX TYPE OR OCCUPANCY TYPE ;COMMERCIALEDUCATIONALRESIDENTIAL ' PRINT 0 0 CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: El PLANS SUBMITTED: YES 0 NO 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 "FURNACE 1 GENERATOR GRILLE . INFRARED HEATER LABORATORY COCKS , - tAKEUPA1�TJN1? , OVEN POOL HEATER - ROOM / SPACE HEATER R ear. OOPTOPUNIT CC&Tt0 /� �� ,/; 0 UNIT HEATER i UNVENTED ROOM HEATER WA1ERHEAIER , OTHER INSURANCE COVERAGE I have a current liability insurance 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 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 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 true and .•ethe the best of m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli-•-- 1'": nent provision Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • PLUMBER-GASFITTER NAME:James Pazakis LICENSE#PL-15030-M SIG , r' MP ® MGF❑ 'JP 0 JGF 0 LPG(0 i CORPORATION ® #280 ..••TNE' .IP IK • LLC ❑# • COMPANY NAME }call Plumbing & Heating, Inc. ADDRESS 447 Old Chatham Road CITY South Dennis STATE MA ZIP 02660 , TEL 508-385-9127F� E C E I V E l3 FAX 508-385-6604 CELL EMAIL HallTechnician(rDcomcast. et 1 o cryo 'gig_ L. a.3O ',0 S I BUILDING C,I 'S'- r _ . f - - - ly Q- .. S31014 M3IA'II NV'Id - #LWM3= $ :33d . • ❑ ❑ J1W213d3H1StlS3Ad3SN011tlOIlddtlSIHl ON SA S3101.1.N01133dSNI INN-11 APN0 3SII 331/01103 M0138 SaION NOLLO3dSN1 ONIUNIIIIJ H911011