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HomeMy WebLinkAboutBLDG-23-002056 # 3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . CITY YARMOUTH MA DATE October 18,2022 PERMIT# BLDG-23-002056 JOBSITE ADDRESS 657 ROUTE 28 OWNER'S NAME MITROKOSTAS NAFSIKA E TR G OWNER ADDRESS S&N REALTY TRUST PO BOX 260 SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 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/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 ❑ 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 Anson Celin LICENSE# 32655 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ANSON CELIN ADDRESS. 26 Capt.Blount Rd, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL ansoncelinna vahoo.com M'4SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM = rt-,, GAS FITTING II+IG WORK =i = CITY_ L/(� .c L MA DATE N ' i n FT 7 PERMIT JOBSITE ADDRESS '$ �f Q 8 +, G43._ OWNER'S NAME di' 5141r3 !4i!, lar OWNER ADDRESS__ il Z$ �._ cJ TYPE OR TEL Co-3 l�Gv PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL CLEARLY NEW: RESIDENTIAL 0 NEW:❑ RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 BOILER 7 8 9 10 11 12 13 11 BOOSTER --- CONVERSION BURNER, _ COOK STOVE - DIRECT VENT HEATER --- DRYER111.1111.111111111 FIREPLACE -� FRYOLATOR _ FURNACE M Minel...1111111 _ 't GENERATOR Ill INFRARED HEATER .............111.11111111111111....111111 LABORATORY COCKS MAKEUP AIR UNIT _�MMNIIIIIII- POOL HEATER ROOM/SPACE HEATEROVEN "'" - ROOF TOP UNIT =�'� tl alma I I MIIN UNVENTED ROOM HEATER --A� ��r_� !0 1� OWATER THER HEATER ■• ( i_ OM_ „ an -- INSURANCE COVERAGE -- I have a current liabili insurance policy or its substantial equivalentvrhich meets the requirements of MGL,Ch.142 YES LrJ„'-JHO/ ❑ I F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT .l, I hereby certify that a work and ll of the details and information I have submitted or entered regarding this application are true and accurate to the best of • ` Massachusetts State Plumbing installations Code and Chapter performed d2 of the Gener the eral Laws. Lawit issued for this application will be in com nca with all P ent provision of theknowledge PLUMBER-GASFITTER NAME � ,� LICENSE# 324 S SIGNATURE MP❑ MGF❑ JP l.?J JGF 0 LPG' ❑ CORPORATION 0# PARTNERSHIP COMPANY NAME C6(r n P I w m 6 i n rI 0# LLC 0# ADDRESS L�o (ct p)- ;,n, akin y) CITY S tit L]AyYrt STATE 0) 4 ZIP 62 GG44 TEL FAX CELL \)l -21jo Ur16Z EMAIL Cie /PIS