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HomeMy WebLinkAboutBLDG-22-007431 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • i7t7{ 'p% `� CITY YARMOUTH MA DATE June 27,2022 PERMIT# BLDG-22-007431 / JOBSITE ADDRESS (1 AVERY LN OWNER'S NAME charles constantine G OWNER ADDRESS 1 AVERY LN SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO ❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER • BOOSTER CONVERSION BURNER COOK STOVE 1 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 UNIT HEATER UNVENTED ROOM HEATER _ WATER HEATER OTHER - - r 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 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. 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❑ LPGI ❑ 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 bendiamantopoulosangmail.com S31ON M3IA321 NVId #1IIJ d $:33d ❑ ❑ 11111213d 3H1 SV S3AH3S NOI1V31lddV SIHl ON SaA S310N NO1133dSNI 1VNld AINO 3Sl 210133dSNI 210d 3OVd SIHl S310N NO1133dSNI SVJ H9f1021 so.()NO '.'."' MASSACHUSE TS UNIFORM APPLICATION FOR A PE'MIT TO 'ERFORM GAS FITTING WORK 1-;, D �,47/ 14 DATE .0 �i ER 4 2t— "31 4ws AP1 //vl��T ?_l I JU 2 4 2I2 B •TE •DDRESS _ / —/A 01ti�1 tR'S NAME ( /[ D ./7/VE- L __ OWI R •DDRESS TEL F I BY f DEPA TMENT -B_E OFF- PRINT NCY TYP COMMERCIAL❑ EDUCATIOF RESIDENTIAL CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO E APPLIANCES 1 FLOORS-4 s:M t 2 o 3 4 5 6 9 10 11 12 '13 t•, BOILER , BOOSTER 1 CONVERSION BURNER I COOK STOVE —� DIRECT VENT HEATER DRYER _I FIREPLACE i FRYOLATOR FURNACE GENERATOR _ GRILLE INFRARED HEATER ___`_I LABORATORY COCKS —I MAKEUP AIR UNIT OVEN POOL HEATER 1 `` ROOM I SPACE HEATER ROOF TOP UNIT - TEST _______I { UNIT HEATER UNVENTED ROOM HEATER • WATER HEATER OTHER I ____. ..i___ l INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalen ich meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG , Y 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ •-.. SIGNATURE OF OWNER OR AGENT I-. 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 complian with all Pertinent provision of the Massachusetts State Plumbing Co and Chapter 142 of the General Laws. �!1 PLUMBER-GASFITTEP NAME 'V mocrop ?u to ENSE#F SIGNATURE MP , MGF - �� G LPGI ❑ CORPORATION❑iE AR VLRSHIP 0 Ii LLC # COMPANY NAME i i° T. /27 .0 DDRESS AtAJT OP CITY L ` STATE_Uvt ` ZIP TE FAX CELL EMA P t ) Z7 PHIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES ROUGH GAS INSPECTION NOTES 'des No THIS APPLICATION SERVES AS THE PERMIT t FEE: 4 PERMIT # PLAN REVIEW NOTES