Loading...
HomeMy WebLinkAboutBLDG-22-003673 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY [YARMOUTH MA DATE 'January 03,2022 'PERMIT ft BLDG-22-003673 JOBSITE ADDRESS IS CADET LN 'OWNER'S NAME LICAUSI ANGELO G OWNER ADDRESS 11 SAINT JAMES RD MEDFORD MA 02155 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BOILER _ BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE 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 0 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 OWNERS 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 E 15496 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME. BENJAMIN DIAMANTOPOULOS ADDRESS. 125 ANTHONY RD, CITY W YARMOUTH STATE MA ZIP 026733776 TEL ' FAX CELL EMAIL ' S310N M3IA32i NVld #±IW2i3d $ 33d El El 111*13d 3E11 SV S3A 13S NOl1VOIlddV SIHI oN sai S310N NOI103dSNI 1VNId Ik1NO 3Sf12I0103dSNl 210d 30Vd SI1-11 S310N NO1103dSNI SVO HO110H ea_fh . _ 06 .. 06 .. , MASSA HUSETTS UNIFORM APPLICATION FOR A P MET TO PERFORM GAS FITTING W �j I WORK E q -• r:: .zire, --OTT ` ��/�`" '�[ �/ � MA DATE L F ��� P._RMIT * 2z — � � �3 0��$ITE AD, RFSS ! r (. OWNER'S NAME B(1rt_ .. By: : u j--• - E AD' RESS3fr9. 4� ENTEL ^ YTYPE ; tiTFAX PRINT a "'` ' Y TYPE COMMERCIAL ❑ EDUC - ,r_ PEAL E RESIDENTIAL CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES .I FLOORS-4 BSIUI 1 23 4 5 6 BOILER 10 !'I 12 •I; 1if 1 BOOSTER f CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER, - I i FIREPLACE FRYCiLATOR FURNACE - , GENERATOR GRILLE -1 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 INSURANCE CDVEE - E I I have a current liability insurance policy or its substantial equivalen . • ich meets the requirements of MGL. Ch. 142 YES f�10 ❑ i I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CO\'ERAG . 'Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY ❑ BOND El • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage rer{uirec! by Chapter 142 of the Massachusetts General Laws, and that ray signature on this permit application yyaives this requirement. SIGNATURE OF OWNER OR, AGENT CHECK ONE ONLY: OWNER ❑ AGENT El `-1_ I hereby- certify that all of the details and information I have submitted or entered regarding this application are true an and that all plumbing work and installations performed under the permit issued for this application will be in cam lianc� with all mino e t provisionbes of knowledge 4 Massachusetts State Plumbing Cod -nd Chapter 'I of the General La s. P th all Pertinent of the PLUMBER-GASFITTER. I I��EP9 V4 `E SIGNATURE 4/2 MP . t,�GF JP JGFE411 LPGI (l CORPORATION [1] F PARTNERSHIP 0 �r LLC ❑ : COMPANY NAME aA *7' c � /4T/7' ADDRF S� CITY - STATE ZIP 95 TEL - 7 FAX CELL EMAI , y�ian7 a QJ e 2 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT t PLAN REVIEW NOTES