HomeMy WebLinkAboutBLDG-18-005859 11\-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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yx, CITY yC��mov 1(�of " MA DATE -1/I"7//Q ! PERMIT#i/-►26'—00 f' _
JOBSITE ADDRESS . 5er lnc4e *Coe OWNER'S NAME (11°kz
GOWNER ADDRESS TEL ;FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL _J RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: .. REPLACEMENT: _ PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
f ._
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 t
OTHER
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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 compliance -nt pro •-ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME James Pazakis LICENSE# 150 : TUR'
MP MGF JP JGF LPGI CORPORATION # C-3984 " NERSHIP ,# 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 GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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