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HomeMy WebLinkAboutBLDG-23-003246 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w BLDG-23-003246 „ CITY YARMOUTH MA DATE December 12,202� PERMIT# li JOBSITE ADDRESS 416 ROUTE 28 OWNER'S NAME NOGALES INC G OWNER ADDRESS 28 REEVES ST SUDBURY MA 01776 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL E RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER • UNVENTED ROOM HEATER WATER HEATER • OTHER 1 • OTHER DESCRIPTION:repair water heater flu 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 ❑ 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! 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: BENJAMIN DIAMANTOPOULOS ADDRESS. 25 ANTHONY RD,25 ANTHONY RD CITY W YARMOUTH STATE MA ZIP 026733776 TEL FAX CELL EMAIL bendiamantopoulosna,gmail.com 4:z4, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK(� E I? CITY Yil- '( I5 T �MA DATE `-7 I. �2- PERMIT# -'' � JOBSITE ADDRESS Li ( 6 T �®P2 Old, 4 (`ER'S NAME v14/ Lf c GOWNER ADDRESS TEL FAX • TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E_ PRINT ❑ RESIDENTIAL❑ CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 0 PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 7. FLOORS-4 BSlul 1 2 3 4 5 6 7 8 9 10 11 12 13 4 BOILER 1> BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER i DRYER - ___ FIREPLACE I FRYOLATOR __ I FURNACE _I GENERATOR 7 I GRILLE INFRARED HEATER ' LABORATORY COCKS i--- _4 MAKEUP AIR UNIT OVEN j; —J— POOL HEATER • - - ROOM/SPACE HEATER ' I ROOF TOP UNIT ' TEST -. UNIT HEATER UNVENTED ROOM HEATERI WATER HEATER J 1 OTHER V ATT Lc)ti- ..-1- ------ L � F INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE ( .BY 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 ❑ AGENT ❑ 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 Ole 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 Pe nt provision of the `-` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. LE PLUMBER-ASFITTER1'AME �' LICENSE# /j l 7'c L SIGNATURE MP D,AGF JP 12( LrJGF LPG( ❑ CORPORATION❑# PARINERSH P 0# LLC❑# COMPANY NAME / i9 -i-, / P �-4 ADDRESS 2'5 / AJ n4Ol J y iZ CITY /Vill- , ' L O t/77-) STATE 14,4 ZIP Ø2J 7 5 TEL,"?, 5k Sgg3 FAX CELL EMAIL be / iviqtd az,40._c