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HomeMy WebLinkAboutBLDG-22-001095 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kr,:i CITY YARMOUTH MA DATE August 26,2021 PERMIT# BLDG-22-001095 JOBSITE ADDRESS 53 RAYMOND AVE OWNER'S NAME Brian Bigelow G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 1 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 1 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 (Benjamin Diamantopoulos I LICENSE# 15496 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPG( 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: (BENJAMIN DIAMANTOPOULOS ADDRESS. 125 ANTHONY RD, CITY 1W YARMOUTH STATE MA ZIP 1026733776 TEL ( FAX 1 CELL 1 EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES ca f'h 'me- pa GaSO.J MASSACHUSETTS UNIFORM APPLICATION FOR A PE IT TO RFORM GAS FITTING WORK ' 1,- CITY II/ AA MA DATE -tr /5- '2/PERMIT 0 JOBSITEADDRESS _ n / . f 4111‘ -'S NAME arty - &,(lei o OWNER ADDRESS -- /f714 6 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT! CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 1;---717i.1 BOILER BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE Jr r—� FRYOLATOR FURNACE GENERATOR -1 - GRILLE INFRARED HEATER LABORATORY COCKS , MAKEUP AIR UNIT _ OVEN I POOL HEATER • 1{ ROOM I SPACE HEATER ROOF TOP UNIT TEST . ......... .._T I UNIT HEATER INVENTED ROOM HEATER — WATER HEATER . OTHER I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent whic eets the requirements of MGL.Ch.142 YES [.-1‘6 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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. • CHECK ONE ONLY: OWNER CIAGENT ❑ •.` SIGNATURE OF OWNER OR AGENT AN 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 'S- and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi , all Pertinent provision of the i Massachusetts State Plumbing Coe and Chapter 142 of the General Laws. /` _ PLUMBER-GAS ITTER NAME p, /ylM14rV bf2o Vlc.ENSE#/`l) 9 SIGNATURE MP v1GFJP P. JGF C LPGI❑ CORPORAT ON❑#i PARTNERSHIP❑# LLC IN 0 COMPANY NAME ,I ,L '4 ,mo2 i . ADDRESS 6 / ` tr OP CITY 1 41 -- STATE AO ZIP V 3 TEL _ j _/' ii 1 FAX CELL EM /92 _. / /i / !I ei'. . 0 S *19' 1 l .snli ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES •