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HomeMy WebLinkAboutBLDG-22-004776 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4BLDG-22-004776 i CITY YARMOUTH MA DATE (February 28,2022 I PERMIT# r JOBSITE ADDRESS 52 ALDEN RD OWNERS NAME HEBERT DAVID W G OWNER ADDRESS HEBERT DEBORAH ANN 68 MERRIAM LN SUTTON MA 01590 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO FIXTURES 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 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY INSURANCE POLICY© OTHER OF 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. 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'James Pazakis I LICENSE# PL-15030-M SIGNATURE MP©MGF❑JP❑ JGF❑ LPG( ❑ CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME JM PAZAKIS,INC. ADDRESS. 447 Old Chatham Road, CITY South Dennis STATE MA ZIP 02660 TEL 5083853677 FAX CELL EMAIL f � S310N M3IAR1 NV-Id #1I1V:13d $:33d ❑ ❑ 1111a3d 3H1 SV S3A213S NOI1d01lddb SIHI oN saA S310N NO1103dSNI 1VNH AINO 3Sf1 b0103dSNI 2IOd 3OVd SIH1 S310N NOLLO dSNI SVJ HJfl021