HomeMy WebLinkAboutG-13-682 a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'lk I(.. 7 CITY Yarmouth MA DATE 1/16113 PERMIT# v/3 - 6(2
JOBSITE ADDRESS:32 New Hampshire Avenue(WestYarmouth) M#16/Block#58/PID#345 OWNER'S NAME:Stigmalne fathers
GOWNER ADDRESS SAME ' TEL . FAX
TYPE OR OCCUPANCY TYPE COMMERCIALEDUCATIONALRESIDENTIAL
PRINT ❑ 0
CLEARLY ; NEW: ❑ RENOVATION: ❑ REPLACEMENT: ® 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
FRYOLATOR
GENERATOR
GRILLE
INFRARED HEATER - ,
LABORATORY COCKS
TARED-AIR UNIT
OVEN .
POOL HEATER
ROOM 1 SPACE HEATER dCEPitD V-2�-
ROOFTOP UNIT ��
'ESE :, D ",...aLkLl.,/
UNIT HEATER - -
UNVENfED ROOM HEATER -
WATER HEATER I
O1HER
•
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES XU NO ❑
IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE'. .
POLICY 22 0
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 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT a
ere.yce I i a a o le•e .isa •in •rmabon ave su•m'rr or en : -• rega •mg 1 ts app'cation are ean•r "::. . now'Bean. ; a
all plumbing work and installations performed under the permit issued for this application will be in compliance w provision • -
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. do
PLUMBER-GASFITTER NAME:James Pazakis LICENSE#PL-15030-M n •.• URE •
MP ® MGF❑ JP ❑ JGF ❑ LPGI ❑ : CORPORATION ® #2803 1'TNER'. • i • LLC❑#
COMPANY NAME Hall Plumbing & Heating, Inc. ADDRESS 447 Old _ oad!-f h'� (-
CITY_South Dennis STATE MA ZIP 02660 TEL 508-385-9127 D i:?, " " U
FAX 508-385-6604 CELL EMAIL HallTechnidanecomcast. JAN 22 201 `,
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ -
FEE $ - - PERMIT i
PLAN REVIEW NOTES
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