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Home My WebLink AboutBldg-20-001952 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Ycurrylo MA DATE PERMIT# /3 �—01d--°G l JOBSITE ADDRESS 7Q 3e - rl0)i'e ttL) OWNER'S NAME D., OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL !O PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: L- 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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. CHECK ONE ONLY: OWNER 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 accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia ith all P ent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �✓ itfi PLUMBER-GASFITTER NAME James Pazakis LICENSE# 1503 'StGNATORE�� MP MGF JP JGF LPGI CORPORATION # C-3984 PARTNERS # LLC # COMPANY NAME: JM Pazakis Inc. ADDRESS 447 Old Chatham Road CITY South Dennis STATE MA ZIP 02660 TEL 508-385-9127 FAX CELL EMAIL ROUGH G.-1S INSPECTION TES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Ok 10/9// erSifr Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES