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HomeMy WebLinkAboutBLDG-22-005561 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '. CITY YARMOUTH MA DATE March 31,2022 PERMIT# BLDG-22-005561 !r`�� JOBSITE ADDRESS 101 ROUTE 6A OWNER'S NAME TILLY SVEN G OWNER ADDRESS OCONNOR BETSY 101 ROUTE 6A YARMOUTH PORT MA 02675-1709 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 1 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 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 • LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY BOND 0 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 LICENSE# PL-15030-M SIGNATURE MP©MGF❑JP❑ JGF 0 LPG! ❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: JM PAZAKIS,INC. ADDRESS. 447 Old Chatham Road, CITY South Dennis STATE MA ZIP 02660 TEL 5083853677 FAX CELL EMAIL S310N M3IA32i NVId #.IW2i3d $:333 ❑ ❑ 11141213d 3H1 SV S3Ab3S NOI1V0IlddV SIHJ oN saA S310N N01103dSNI 1VNN /LINO 3Sl 2l0103dSNI 210d 3OVd SIH1 S310N N01103dSNI SVO HJf102'