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HomeMy WebLinkAboutBLDG-22-001379 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '� j CITY YARMOUTH MA DATE September 09,202 PERMIT# BLDG-22-001379 JOBSITE ADDRESS 46 GROUSE LN OWNER'S NAME Terrance Shea G OWNER ADDRESS 46 GROUSE LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:D 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 1 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY El 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© 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 S310N M3IA3b NVId #1IW213d $:33d ❑ ❑ 11 1 d 3H1 St/S3AiI3S NOIlVOIlddli SIHl oN saA S310N N01103dSNI 1VNId AINO 3Sf1 b0103dSNI 210d 3OVd SIHI S310N NOI133dSNI SVO H0001:1 :" MASSACHUSETTS UNIFORM APPLICATION FOR A PE IT T PERFORM GAS FITTING WORK L1j 1 .. CITY 1-41 MA DATE PERMIT 4s 2' (v JOBSITE ADDRESS 6-.120 �� R'S NAME --� f I a� Ili OWNER ADDRESS P "' TEL FAX ri) PO' OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El---"----- X - r�.EmR i,Y NEW: RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS--f BSM 1 2 3 4 5 6 7 & 9 10 II 12 •I; 14 BOILER '--- I BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER _ I DRYER -�-_, FIREPLACE - ' FRYOLATOR FURNACE GENERATOR GRILLE I--I INFRARED HEATER LABORATORY COCKS . MAKEUP AIR UNIT OVEN POOL HEATER _ - L ROOM I SPACE HEATER ' ROOF TOP UNIT TEST .. I _ UNIT HEATER UIJVENTED ROOM HEATER • WATER HEATER OTHER I ' INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent whi ets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA CHECKING TIE 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 ri, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat o 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 al . ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Li j PLUMBER-GASHTTCR i� - 67144,16_ 4CEhiSE 154 SIGNATURE MP M.---1-;1- J [I-46F LlP�G,I(❑ C� RPORATION❑tF PARTNERSHIPJ ❑# LLC� fl COMPANY N - 'V I Iy-`14A (kJ IDY o�LODDRESS �� /,� rim / Lb CITY `A �/ v / _ STATE`' '64 ZIP TEL / TEL FAX CELL ,�6 .2C'O 5 q 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