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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
egg, CITY Yc rmoJpr-� I MA DATE 5/ 1/8 PERMIT# 111 46
JOBSITE ADDRESS 5/'or - Coad2- I OWNER'S NAME Siicc...v,ne (Y)c f u l° e
GOWNER ADDRESS I TEL SO8-3644-3354 !FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL _j EDUCATIONAL J RESIDENTIAL 34
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: k-? PLANS SUBMITTED: YES NO
APPLIANCES -1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER x
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 jC
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 compliance t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME James Pazakis LICENSE# 150 SIGN
MP MGF JP JGF LPGI CORPORATION # C-3984 TNERSH # 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