HomeMy WebLinkAboutBLDG-23-001062 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
� CITY YARMOUTH 1 MA DATE August 29,2022 PERMIT# BLDG-23-001062
JOBSITE ADDRESS 111 CROWELL RD OWNER'S NAME LADIN EDWARD L TRS
G OWNER ADDRESS LADIN KATHRYN C 2 LEAFY LN LARCHMONT NY 10538 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL. ❑ RESIDENTIAL El
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CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El
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
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER 1
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 El 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.
S GNATURE 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 plLmbing 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 0 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 1 CELL EMAIL
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