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HomeMy WebLinkAboutG-13-358 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ayr CITY Yarmouth MA DATE 10/30/12 PERMIT# JOBSITE ADDRESS 741 Willow Street(S.Yarmouth) M#42.131/P#6352 OWNER'S NAME:Orth/Newcomb GOWNER ADDRESS 17 Warren Lane Weston, MA 02493 TEL 508)398-9542 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ri PRINT CLEARLY NEW: ❑ RENOVATION: 0 REPLACEMENT: 2t] PLANS SUBMITTED: YES ❑ 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 DiIREO1 vENY—HEATER DRYER PREPTACE FRYOLATOR FURNACE ..a._....._.... ._.__.w _._ _ `. ... __ `GENERATOR GRILLE -INFRARED HEATER ::LABO-RA-ToRYcoCRS 'MAKEUPAIRUNIT. OVEN POOL HEATER -ROOMTSPACI"HEATEK ROOFTOP UNIT `TEST UNIT HEATER A q- UNVENTED ROOM HEATER j `WATER-HEATER OTHER 1y$t INFURARCECM, RAG: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES © NO o I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY ng 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. j 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 true and- •ra-et the b my k w e ge an tat all plumbing work and installations performed under the permit issued for this application will be in compliance w' - -II Peril.-n vision of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME:James Pazakis LICENSE#PL-15030-M IGNATURE j MP EI MGF❑ JP 0 .JGF ❑ LPG' ❑ CORPORATION ® #2803 - 'RTNERSHI LLC ❑# COMPANY NAME Hall Plumbing & Heating, Inc, ADDRESS 447 Old Che :n- _ CITY South Dennis STATE MA ZIP 02660 TEL 508-385-9127 FAX 508-385-6604 CELL EMAIL HallTechnician@comcast.net - NOV O 2 2012 J but W ING LEFT-"""-" By ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No • THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# _ A' Sag PLAN REVIEW NO'('ES