HomeMy WebLinkAboutBLDG-15-002111 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTINGWORK
tetgi CITY- - MA DATE 104-5Y PERMIT#
4,,4;r•
JOBSITE ADDRESS ceCMaxüc tag.o.... M# / P# ti.Ite..>" OWNER'S NAME:
GOWNER ADDRESS SAME e TEL FAX
TYPE OR ! ,
OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 I RESIDBffIAL )
PRINT
CLEARLY NEW:0 RENOVA110N o REPLACEMENT: EJ PLANS SUBMI IED: YES 0 NOD
APPLIANCESI. FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTERCONVERSION BURNER
COOK STOVE • •
DIRECT WN T HEATER
DRYER
FIREPLACE
FRYOLATOR .
1:111NACE X
GENERATOR
GRILLE •
INFRARED HEATER . •
IABORAIORY COCKS
altEtrAIRTJNIT I
OVEN •
POOL HEATER
ROOM / SPACE HEATER
ROOFT OP UNIT
TEST,
•
UNIT HEATER
((C
UNVENTED ROOM HEATER
T
WAIIL-R HEATER .
OTHER • ,
IN RANCE COVERAGE .
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 „ YES El NO 0 ;
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW_. , _ H _
UABIUTY INSURANCE POLICY El 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 AGENT 0
SIGNATURE OF°INNER OR AGENT •
I hereby certify that all of the details and information I have submitted or entered regarding this application are true a•• •• ate e best of y knowledge and that
all plumbing work and installations performed under the permit issued for this application will be in compliance I e ' ent provision the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • • '
•Or
PLUMBER-GASFITTER NAME James Pazakis LICENSE#PL-15030-M A , SI NATURE
MP Ei MGM: JP JGF 0 LPGI 0 CORPORATION #2803 .1•TNER IP 0# LW 0#
COMPANY NAME Hall Plumbing & Heating. Inc, ADD'ESS 447 0• Chatham Road
CITY South Dennis STATE MA ZIP02660 TEL 508-385-9127
FAX 508-385-6604 • CELL EMAIL HallTechniciaHacomcastnet
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#
PLAN RFtiVIEW NOTES