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Home My WebLink AboutBLDG-22-003570 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 28,2021 PERMIT# BLDG-22-003570 JOBSITE ADDRESS 1341 ROUTE 28 OWNERS NAME PANAGIOTU MATTHEW W TR G OWNER ADDRESS ZOITSA PANAGIOTOU TRUST 25 TERRACE DR WORCESTER MA 01609-1415 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 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 I SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:gas pipe repair INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 at plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Jared Wilber LICENSE# 15219 SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: JARED WILBER ADDRESS. 474 WINSLOW GRAY RD. CITY S YARMOUTH J STATE MA ZIP 026644317 TEL FAX CELL EMAIL S310N M3IA321 NYld #1l d3d $ :33d ❑ D 110183d 3Hl SY S3A2i3S NOI.V011ddV SIHl ON SaA S310N NO1103dSNI 1VNId /LINO 3Sfl 2 0103dSNI 210d 3UVd SIH1 S310N NO1103dSNI SVO HOf102] • MAS A.CHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK -,y CfT ��ICN1Q(i�t'�cr', DATE g"/ '-,7 / PERMIT# L2- 7 0 DEC 1 6 2 /SIT ,AiiDRESS r 3 z/.. A 7" p2 pj OWNER'S NAME t u- 0. td1-IA- BOIL DE T•.RES, TEL FAX By"TV_�R- -i�,-nr_ PRINT OC tUf'k :,Y TYPE COMMERCIAL[] EDUCATIONAL ❑ RESIDENTIAL ❑ CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-I BSM 1 2 3 1 5 6 8 9 10 11 12 13 1F BOILER r—� BOOSTER --i CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYCiLATOR i FURNACE GENERATOR • GRILLE r I INFRARED HEATER —7 LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM!SPACE HEATER ROOF TOP UNIT r TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER fLG 6, ..1/ t 4'1 ..�o w5 r‘i) INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES t❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY [i OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I ant 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 0 SIGNATURE OF OWNER OR AGENT "1, 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 Li j Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 3 4.1/Ned `,,d I tb ev' LICENSE# ( 5J,19 pi( ktAd02.)t_ SIGNATURE MP ! MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION El# PARTNERSHIP❑# LC 0# COMPANY NAME .3 q`T Q A 5 k\ lA Yd�ec 1 'A ADDRESS U( 7 w l Ir k G,,,A,. k CITY 5, 1Qp >, 4OLttl i STATE /Vj 6. ZIP 0 1 b I ' -/ TEL h c�a;1 3.. if y FAX CELL (.Arne EMAIL Jar chic L2,3 . /_t'Y1C{jt., cOm ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT 0 PLAN REVIEW NOTES