HomeMy WebLinkAboutBLDG-20-004139 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1i y CITY /czrrhv MA DATE I/a7/av PERMIT#—A —10-0-651 7/6?
JOBSITE ADDRESS S� Scrn'roI L we_ OWNER'S NAME tYla J''t I IO
GOWNER ADDRESS TEL FAX
YI'F: 012
I'KI\ I OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL(IQ
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CLEARLY NEW: RENOVAT!ONX) REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z 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
• GENERATOR
— TL— —
GRILLE
i INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER _
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST — i
HF :f<
UNYERCONIHEATERJNTED
C 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 codify that all of the details and information I have submitted or entered regarding this application are true and accurate to t - . . • y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complianc rtinent provi on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME James Pazakis LICENSE# 15030
SI AT•'E
OP MGF JP JGF LPGI CORPORATION / # C-3984 P NER .'IP # LC #
1P.1 Pazaki;Inc. ADDRESS 447 Old Chatham Road
CITY South Dennis STATE MA ZIP 02660 TEL 508-385-9127
FAX CELL EMAIL
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