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Home My WebLink AboutG-13-021 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK CITY Yarmouth(West) MA DATE 07/06/12 PERMIT# • 2 �vw��nt JOBSITE ADDRESS 17 Silver Leaf Lane OWNER'S NAME:0 wen G OWNER ADDRESS SAME TEL 508-778-6367 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 133 PRINT CLEARLY NEW: ® RENOVATION: 0 REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NOS 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 NFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT � OVEN POOL HEATER ROOMT"SPAOE"AEATER ROOF TOP UNIT TEST 't II IK l l UNIT HEATER l /ti�✓o� +J T ED ROOM HEATER ) 4 09 Z0i2 1 WATER HEATER OTHER Pi— IN r y. ' 'VERAG.1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO ❑ I 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 ■ efF T 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- urate ' e best of my kn edge and that I all plumbing work and Installations performed under the permit issued for this application will be in compliance wit. -II Perti provision of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME:James Pazakis LICENSE#PL-15030-M ' ® IGNATURE MP ® MGF❑ JP ❑ JGF ❑ LPG] ❑ CORPORATION ® #2803 PARTNERSHIP ■ ° LLC ❑# 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 HallTechnicianat comcast.net ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES