Loading...
HomeMy WebLinkAboutBLDG-22-001101 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F l 7�a CITY IYARMOUTH MA DATE August26,2021 PERMIT# BLDG-22-001101 JOBSITE ADDRESS 29 OLD CEDAR LN OWNER'S NAME BELL JACK R G OWNER ADDRESS BELL CAROLYN P 29 OLD CEDAR LN SOUTH YARMOUTH MA 02664-1027 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL EI PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO FIXTURES FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 - 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 - - i 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 ❑ 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❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: JM PAZAKIS, INC. ADDRESS. 447 Old Chatham Road. CITY South Dennis STATE MA ZIP 02660 TEL 5083853677 FAX CELL EMAIL S310N M3IA3N NVId #11114213d $:33d ❑ ❑ 1JW213d 3Hl SV S3Ai13S NOIlv011ddtl SIHl oN SaA S310N NO1103dSNI 1VNId AINO 3Sf1 NO103dSNI 210d 30Vd SIH1 S310N NO1103dSNI SVO HOl021