HomeMy WebLinkAboutG-13-084 ,� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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2 CITY Yarmouth MA DATE 07/30/12 PERMIT# 3' 0B4
JOBSITE ADDRESS 23 Wood Duck Rd (West Yarmouth) M#6/ P#2 OWNER'S NAME: Clay
GOWNER ADDRESS SAME TEL 508-775-7867 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 29
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CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES ❑ NO❑
TO.00
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER __.. �� �� �•
CONVERSION BURNER
COOK STOVE D
DIRECT VENT HEATER EC E l V E
DRYER
FIREPLACE 1
FRYOLATOR �VV
FURNACE ._..
GENERATOR BOLD)
of
GRILLE t By
INFRARED
LABORATORY COCKS 1
MAKEUP AIR UNIT' w M1
OVEN 'S
POOL HEATER 1
`ROOM- SPACE HEATER
ROOFTOP UNIT
TESTco
UNIT HEATER
WATER HEATER j
01 HER
IN URAN ECOVERAGE
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 ® OTHER TYPE INDEMNITY ❑ 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 true a.• accura o -- •est of my owledge and that
all plumbing work and installations performed under the permit issued for this application will be In complian.- ,ith all Pe. : provision of e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME:James Pazakis LICENSE#PL-15030-M SIGNATURE
MP ® MGFD JP o JGF 0 LPG' ❑ CORPORATION ® #2803 PARTNERS ' 1 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 HallTechnician aOcomcast.net