HomeMy WebLinkAboutBLDG-23-001982 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`'" - CITY YARMOUTH MA DATE October 13,2022 PERMIT# BLDG-23-001982
r
JOBSITE ADDRESS 22 DUTCHLAND DR OWNERS NAME PAULDING ROBERT
G OWNER ADDRESS PAULDING NANCY 22 DUTCHLAND DR YARMOUTH PORT MA 02675-2415 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III
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/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 0
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 Q MGF❑JP 0 JGF❑ LPG/ ❑ CORPORATION❑# PARTNERSHIP ❑it LLC❑tt
COMPANY NAME: BENJAMIN DIAMANTOPOULOS ADDRESS. 25 ANTHONY RD,25 ANTHONY RD
CITY W YARMOUTH STATE MA ZIP 026733776 TEL
FAX CELL EMAIL bendiamantopoulos/Sgmail.com
•
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
s
w /�
TiO ` CfTY__T Ail/ P LUTC-1/IT1• MA DATE PERMIT# L:' 1 ZSZ—
JOBSITE ADDRESS_22- A ,lgt ,S NAME
OWNER ADDRESS ` - - TEL
FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL[]----------
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES
❑ NO❑
APPLIANCES 1. FLOORS—F BSM 1 ,
BOILER 2 3 4 5 6 7 8 9 to 11 12 1;
LIL
BOOSTER
CONVERSION BURNER 1
COOK STOVE _
DIRECT VENT HEATER
DRYER - _______I__
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER _ TT
LABORATORY COCKS — -___ r
MAKEUP AIR UNIT , •
OVEN I
POOL HEATER �_�
•
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST ,
T HEATER -- � --
UNVENTED ROOM HEATER •
WATER HF 1 ER _
OTHER � J ` y�I,-4- /(
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE B KING 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 ❑ AGENT 0
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 'th all Pertinent provision of the
Li j
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER N 4E LICENSE#/6— SIGNATURE
MP uF L� JGF
n LPGI 0 C RPORATION❑#i PARTNERSHIP # LLC❑
COMPANY N ME V P f Z ( P I-1- ADDRESS r ' J
CITY � G n ,
.E.S �IV f
V dt__ STATE_ * ZIP i, . - . e�
TEL U.• --1 and
FAX CELL EMAI , 2 LA
i
1
i
Gj
czzl
o
I 0
1 P.,
a
Gr./
1
1rl,
I
i
I
=❑
0 <n
a�i�
G7 w
1 r
I • r�rJi
rn w >
.. -t
cn
c4 al P4
>
C9 o.
< a
Cr) L.,
ra
r"' Q_
a
L
I
I
11
U`.]
C)
F+
G
I
c
1 cri
kL9
n
1
I
1