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HomeMy WebLinkAboutBLDG-15-002115 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK, . ct, CITYSCb /�^' %- MA DATE lbl1 kf PERMIT# !te0U 15 'O®Q//% JOBSITE ADDRESSS/ Ce-.0101,CIcsc M# / P# e,r•6cr— Whelan OWNER'S NAME GOWNER ADDRESS , SAME TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT • CLEARLY NEW:❑ RENOVATION:0 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 X BOOSTER CONVERSION BURNER COOK STOVE -DICVENnitAMR DRYER FIREPLACE FRYOLATOR.. .. . ... ._ . _ _ . "FURNACE —.— GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT • OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER / UNVENTED ROOM HEATER WATER HEAI ER OTHER del 7.1� • d- • _ 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 IJABIIJTYINSURANCE POUCY ® 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT i I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a •• ate r r•es o my w e•ge an• a all plumbing work and installations performed under the permit issued for this application will be in compliance wi.• : Perth•• provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME:James Pazakis LICENSE#PL-15030-M SI T •E MP® MGF❑ JP ❑ JGF ❑ LPG! ❑ CORPORATION ® #2803 P :0-'ERS • ❑# LLC ❑# COMPANY NAME Hall Plumbing & Heating. Inc. AD': SS 447 01. hatham Road CITY I South Dennis STATE MMA ZIP 02660 TEL 508-385-9127 FAX 508-385-6604 CELL EMAIL HaifTechnicianecomcastnet i ROUGH GAS INSPECTION NOTES , THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES - Yes No THIS APPLJCA110N SERVES AS THE PERMT 0 0 FEES PERMIT PLAN REVIEW NOTES • - . • . ,