Loading...
HomeMy WebLinkAboutBLDG-21-007544 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK L11mil CITY YARMOUTH MA DATE June 28,2021 PERMIT# BLDG 21-007544 JOBSITE ADDRESS 29 KATES PATH VILLAGE OWNER'S NAME katherine greely G OWNER ADDRESS 29 KATES PATH YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ 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 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 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 0 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 0 JP 0 JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0# 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 ea. . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TOPERFORM GASFITTING WORK RI II' `...•-_ z MA DATE 2 �� PERMIT I-O�- Z( - 75 .0 N I� OBSITE ADDRESS 2 gill OWNER'S NAME > G„, ' s WNER ADDRESS C� TEL FAX W 1J0 ° V Y �, ,Z CCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL W LE. ., J EW: Il RENOVATION: ❑ REPLACEMENT: (l PLANS SUBMITTED: YES ❑ NO ❑ ra_n APP-1.k1Ira:, -I FLOORS--4. BSIv1 1 2 3 4 5 6 7 9 10 11 12 13 I 14 BOILER BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER i DRYER ' i FIREPLACE FRYOLATOR I FURNACE I GENERATOR I GRILLE I INFRARED HEATER I I LABORATORY COCKS MAKEUP AIR UNIT I OVEN 1 i POOL HEATER 1ROOM ! SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER I WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of I1GL. Ch. 142 YES NO ❑ I IF YOU CHECKED YES, PLEASE. INDICATE THE TYPE OF COVE .BY 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 Massarhu: eats General Laws, and that my signature on this permit application waives this requirement. i 1 I CHECK ONE ONLY: OWNER =1 AGENT ❑ •--, SIGNATURE OF OWNER OR AGENT i si.' I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc ate to the best of my knowledge I `, and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l Lo PLUMBER-GASFITTER NAME NI 9/ftMilljlOrade05 LICENSE #1 SIGNATURE MP ❑ MGF _ ADDRESS P ❑ JGF (l LPGI In CORPORATION [1] F PAR VERSHIP El # LLC ❑ #: COMPANY NAMEb-Jo7 *iLy �� Sc 40T-f-INY & /t- A , CITY > t4O V l v STATEMA ZIP e TEL FAX CELL EMAIL U co j 1 I W H 0 Z. 1 Z 0 i H I L w 1CO n4 i 1 4 1 1 I I °I:] a m Z aEl j ti 1 r4 Z r a a w w 0 o AACO Q CO a_ a. I— U- I 1 w • I C i 1 z 1 C) 1 CC) 1 w 1 ccr) I z j d i V 1 1