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HomeMy WebLinkAboutBLDG-15-002113 " , _-.-.MASSACHUSETTS.UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f�ryII� 1�; \\;I; CITY I'h�cfMOcS-I'�MA DATE jolts--//y PERMIT# *-Ob '"''IS0062/4 • JOBSITE ADDRESS /3y I (Ste- g M# i P# Ol ynnp�c, PPA, h/OuscOWNER'S NAME:, G � 4- OWNER ADDRESS SAME TEL . FAX. TYPE OR • OCCUPANCY TYPE COMMERCIAL ] I EDUCATIONAL 0 RESIDENTIAL ❑ 1 PRINT �l CLEARLY NEW:0 RENOVATION: 0 REPLACEMENT: 0 . PLANS SUBMITTED: YES 0 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 - IR DRYER FIREPLACE `FRYOLATOR —FURNACE K . GENERATOR • GRILLE F F , F INFRARED HEATER LABORATORY COCKS . MAKEUP AIR UNIT r OVEN POOOLL HEATER • ROOM I SPACE HEATER F ROOF TOP UNIT I . TEST UNIT HEATER UNVENTED ROOM HEATER . WATERHEAtf3t ; i - OTHER . IRSITRAACECO'.'E- • 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 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.❑ 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 : o my o ,age an. 1 a all plumbing work and installations performed under the permit issued for this application will be in compliance !:_rIIl " • • ision of the 1 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - �7 . PLUMBER-GASFITTER NAME:James Pazakis LICENSE#PL-15030-M : SIG aTURE i MP ® MGF❑ JP ❑ JGF❑ LPG! 0 CORPORATION ® #2803 P . ERSHIP ■# LLC ❑# COMPANY NAME Hall Plumbing & Heating. Inc. . ••RESS 447 • . C.-. am Road CITY South Dennis STATE MFS; ZIP 0266Q TEL 508-385-9127 FAX 1 508-385-6604 • CELL EMAIL HalfTechnicianOcontcastnet , • . C: V 4 w ..` • $2101.1 MAIA321 NYU 1 #1MRI3d $ v33d _ - 0 0 1IN213d HELL SY S3A213S NOLLVO1lddV SIHI ON ODA - SILOAI NOLLO3dSNI'IVNLi A INO asa NO,LJaasNi UOa aDvd sLIi.L S1.LON NOLLO3aSNI SV9 119110U