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HomeMy WebLinkAboutBLDG-23-002575 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w' -, CITY YARMOUTH --I MA DATE November 09,202; PERMIT# BLDG-23-002575 Pi JOBSITE ADDRESS 42 DEBS HILL RD UNIT 3A OWNER'S NAME CAMPANE ROSEMARY ANN G OWNER ADDRESS 42 DEBS HILL RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12 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 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 ❑ 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' ❑ CORPORATION❑# PARTNERSHIP 0# 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 ""'. IIMmtmw MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1---= :Ps MA DATE PERMIT# JOBSITE ADi RESS ! ` I ��b V W ( OWNERS NAME ` �r M. i�}�r-/� ' . '" WI ER ADD ,ESS �iD c t'®66 TEL FAX Bvp�UN� JF TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: N/ PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 1 FLOORS-+ 6SM BOILER 1 ' 3 4 ERF11111110111111111111111.11 BOOSTER 13 14 CONVERSION BURNER v COOK STOVE DIRECT VENT HEATER - DRYER FIREPLACE FRYOLATOR — allira 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 Era _______ IIIIIP INSU E I have a current Iiabib insurance policy or its substantial equivalent hicOhVme is the requirements of MGL.Ch.142 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO\'ERAG , CHECKING THE APPROPRIATE BOX BELOW YES L NO ❑ LIABILITY INSURANCE POLICY OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insunce overageOTHESi TYPE INDEMNITY ❑ BOND 0 l. OC APC f/V.re,e0 ti tO Massachusetts General Laws,and that ro signature on this permit application weives this requi emea t wirer!by Chapter 142of the '- SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 't I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a and that all plumbing work and installations performed under the permit issued for this application will be in compliance with .I Massachusetts State Plumbing Code nd Chapter iq2 of the General Laws, ccura` to the best of myknowledge �� � rtinent provision of tl-e PLUMBER-GASFITTEF AME � E/ , LICENSE#/� �- ItnP I M�,F LJ J JGr SIGNATURE LPGI ❑ CORPORATIifN❑li COMPANY NA - i�`j�� �� PARTNERSHIP El# LLC CITY ` _/'✓ �0v ADDRESS �� ill " ' STATE gig- ZIP d Z. -7� y FAX �•7. FA CELL EMAI / / / i GV 0_5 i7 `��•-,if fl pit",