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HomeMy WebLinkAboutBldg-22-00833 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �' 4 CITY YARMOUTH MA DATE August 13,2021 PERMIT# BLDG-22-000833 I i_ JOBSITE ADDRESS 23T WHITES PATH UNIT 2 OWNER'S NAME geoge del G OWNER ADDRESS SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 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 ROOM I 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 Benjamin Diamantopoulos LICENSE# 15496 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: BENJAMIN DIAMANTOPOULOS ADDRESS. 25 ANTHONY RD, CITY W YARMOUTH STATE MA ZIP 026733776 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE:$ PERMIT# PLAN REVIEW NOTES 4 MASSACHUSETTS UNIFORM APPLICATION FOR A ERNII TO PERFORM GAS FITTING WORK CITY e;� ` _4 , '�!/ . . MA DATE PERMIT JOBSITE ADDRESS I WNER'S NAME4-16#:•6C1247 GOWNER ADDRESS 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;-j 1c BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I --_—DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR RRv (('�� F I V D I — GRILLE _`1...._. _..___.._.. INFRARED HEATER LABORATORY COCKS rll • TT�-ZOr MAKEUP AIR UNIT —_ OVEN BL. ILDIN 3 DEI-ARTM NT POOL HEATER by — --_ ,:- ROOM I SPACE HEATER ROOF TOP UNIT TEST ... ... UNIT HEATER '. (INVENTED ROOM HEATER WATER HEATER OTHER _ j I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivale ich meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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. CHECK ONE ONLY: OWNER ❑ AGENT 0 ,-3 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 a urate 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 h all Pertinent provision of the l L Massachusetts State Plumbing Cod nd Chapt 42 of the General Laws. aos L PLUMBER-GASFITTE ME MAMA)/Or LICENSE tt/51/ SIGNATURE MP ,AGF JP JGF LPG( CORPORATION1 ❑ 0# PA.RTNERSHI LLC❑##COMPANY N E G ADDRESS 25 ñA1ThOiV/ CITY STATE iVii ZIP 0 7 TE 5‘0 5f1� FAX CELL @bA(4Q'C I 01 F % C._ 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