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HomeMy WebLinkAboutBLDG-21-007547 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 28,2021 PERMIT# BLDG 21-007547 is ,..,r, B TE ADDRESS 8A&88 ROSEMARY LN OWNER'S NAME West Yarmouth series four LLC JO SI G OWNER ADDRESS MA 02601 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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 , 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 El 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, CITY W YARMOUTH STATE MA ZIP 026733776 TEL FAX CELL EMAIL 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 ;"4''.- .aA-� : : MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 I-- e4e;W:lt:::_: 1 � ;ls fT( MA DATE ` PERMIT .r JOBSITE ADDRESS WNER'S NAME :,.''': bWNER ADDRESS TEL FAX TYPE OR L.PRINTOCCUPANCY TYPE COMMERCIAL [1] EDUCATIONAL E RESIDENTIAL LEAP1 NEW ❑ RENOVATION: ❑ REPLACEMENT: E PLANS SUBMITTED: YES ED NO ❑ APPLIANCES -.i FLOORS--4. 6SIA 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 FRYC)LATOR FURNACE I GENERATOR GRILLE INFRARED HEATER I i LABORATORY COCKS MAKEUP AIR UNIT OVEN II POOL HEATER I ROOM / SPACE HEATER ; i ROOF TOP UNIT TEST _ - --- • .o.- ----------- , UNIT HEATER _-.. UNVENTED ROOM HEATER _ WATER HEATER _ OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of liIlGL. Ch. 142 YES ❑ NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND E. 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 ray signature on this permit application waives this requirement. i ; . CHECK ONE ONLY: OWNER ❑ AGENT ❑ • SIGNATURE OF OWNER OR AGENT J ' I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac rate 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 w'y : Pertinent provision of the ,�I Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / 1 PLUMBERASFITTE AME LICENSE # I'M SIGNATURE MP , MGF JP JGF LPGI ❑ CORPORATION ❑ 4 PARTNERSHIP ❑ # LLC ❑ # 1 COMPANY" NAMEt-/-66N4- eci--- /71- ADDRESS li) CITY I I H STATE ZIP 0 9 TE D a 6 1 Mfr. FAX CELL EMAIL S • V4 I _0/ ROJJG1I GAS i fSPE� rats ,� THIS PAGE FOR INSPECTOR USE ONLY FINAL Ir--ISPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT ft PLAN REVIEW NOTES