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HomeMy WebLinkAboutBLDG-22-001003 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE August 23,2021 PERMIT# BLDG-22-001003 JOBSITE ADDRESS 30 GLENWOOD ST OWNER'S NAME KOURAFAS JAMES R G OWNER ADDRESS P 0 BOX 741 STOUGHTON MA 02072 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO al 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 • 7 FIREPLACE FRYOLATOR FURNACE • GENERATOR GRILLE • INFRARED HEATER • LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER • ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 all NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY CI 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 (Albert Cassano LICENSE# 19015 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP I:1# LLC ❑# COMPANY NAME: (Cape Cod Mechanical Systems Inc I ADDRESS. 8 Fruean Way, CITY (South Yarmouth 1 STATE MA ZIP 102664 I TEL 15083947501 FAX 1 'CELL 15087769536 1 EMAIL 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE:$ PERMIT# PLAN REVIEW NOTES