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HomeMy WebLinkAboutBLDG-23-004012 w � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK n � CITY YARMOUTH MA DATE January 23,2023 PERMIT# BLDG-23-004012 JOBSITE ADDRESS 26 ANASTASIA RD OWNER'S NAME GALLAGHER AMY T G OWNER ADDRESS GALLAGHER JAMES P 210 MAIN ST WINTHROP MA 02152 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:ID PLANS SUBMITTED: YES El 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 FRYOLATOR FURNACE 1 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 El OTHER OF INDEMNITY 0 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. 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❑ JGF❑ LPG( CORPORATION❑# PARTNERSHIP ❑# LLC El# COMPANY NAME: IBENJAMIN DIAMANTOPOULOS ADDRESS. 25 ANTHONY RD,25 ANTHONY RD CITY IW YARMOUTH STATE MA ZIP 026733776 TEL I FAX I CELL I EMAIL Ibendiamantopoulosna,pmail.com MASSACHU ETTS UNIFORM APPLICATION FOR A ^ERMIT TO PERFORM GAS FITTING WORK CITY lir I A.414 / i4A DATE ilEW PERT T# 2 3, q GG Z JOBSITE ADDRESS , 1 V/ 4 �/� "ER'S NAME gritidifreilL0 el GGVVNER ADDRESS TEL FAX APE OR OCCUPANCY TYPE COMMERCIAL E PRINT ❑ DUCATI • ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ N0❑ APPLIANCES 1 FLOORS-4. BSM 1 2 5 6 7 8 9 10 11 12 13 BOILER --�-- ?� BOOSTER --� � -CONVERSION BURIJEP, . i � COOK STOVE C---_ --- f DIRECT VENT HEATER _--_— __—== I DRYER _—�--� — FIREPLACE -- —_--- i FRYOLATOR �_�-1 __— FURNACE MEM _ GENERATOR `i --_— �_-- GRILLE 0--= M _—_ INFRARED HEATER LABORATORY COCKS == �A ��mi IM . C MAKEUP AIR UNIT _ _� �,f xesmau _ OVEN ______ i_____I ___ POOL HEATER M=—== 11.11111111t11M1' �, ' ROOM I SPACE HEATER —11I1�M`� ROOF TOP UNIT —_C IUIM r_ . iBU_lL lNG i ffind m UNIT HEATER UNVENTED ROOM HEATER ===�WATER HEATER _=_�mi �OTHER M allinn INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES r NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE B CKlNG 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. .3 CHECK ONE ONLY: OWNER ❑ AGENT 0 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 a 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 complian th all Pertinent provision of the `` Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. PLUMBER-G FITF- AME f7jpoUg71,7 /OP'O LICK /511/9 , SIGNATURE MP MGF JP JGF COR,POI�TION 0# PARTNERSHIP4/7-11-0 ❑# LLC 0 COMPANY N E frig/90=r- p o0�{�� I¢ ADDRESS g5— CITY /f92A4Ot77f STATE NW ZIP I. ZZ_ TEL 01 30 0 39Y3 FAX CELL EMAIL �� , i II 0 IA Ll 110 0 A /� C .I() .-7