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HomeMy WebLinkAboutBLDG-22-004042 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e f' CITY YARMOUTH MA DATE January 21,2022 PERMIT# BLDG-22-004042 tl�. JOBSITE ADDRESS 233 SETUCKET RD OWNER'S NAME JACKSON JEAN B LIFE EST G OWNER ADDRESS 233 SETUCKET RD YARMOUTH PORT MA 02675-2247 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 911 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE _ 1 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 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 El MGF ❑ JP 0 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 M3If321 NVId #1101U3d $:33d ❑ ❑ 111183d 3H1 SV S3AH3S NOIlVOIlddV SIHl oN s2A S310N N01133dSNl IVNId AlNO 3Sf1 N0103dSNI a0d 30Vd SIHI S310N N01103dSNI SVJ H9l021