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Home My WebLink AboutBLDG-22-000122 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `#, CITY YARMOUTH MA DATE July 08,2021 PERMIT# BLDG-22-000122 JOBSITE ADDRESS 29 KATES PATH VILLAGE OWNER'S NAME katherine qreely G OWNER ADDRESS 29 KATES PATH YARMOUTH PORT MA 02675 TEL_ TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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 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 ❑ 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 III 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 ,r " 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 0 PERFORM GAS FITTING WORK t -;4 R:.—• ,:o CITY MA DATE 7/ /2L PERMIT JOBSITE ADDRESS VVNER'S NAME Ka+kertr_ Grce (.1y G OWNER ADDRESS TEL FAX^ Fn. TYPE OR PRINT OCCUPANCY T E COMMERCIAL L I EDUCATIONAL 1— RESIDENTIAL CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES FLOORS-+ BSIvi 1 2 3 1 5 6 9 1i1 11 12 *I;; 1 1 4 BOILER BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER L DRYER, r R E C E I V E [3 - FIREPLACE --- l FRYOLATOR 1 FURNACE JUL 0 8 2i)21 [ GENERATOR 1. GRILLE B,JILDIhG hFARTMCN I INFRARED HEATER ay -- , LABORATORY COCKS 1 • MAKEUP AIR UNIT I OVEN POOL HEATER I ROOM ! SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER ` WATER HEATER - I OTHER INSUR.ANC E COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL. Ch. 142 YES K 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG - CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 7 BO1 D n l OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Ii Massachusetts General Laws, and that my signature on this permit application waives this requirement. I 3 CHECK ONE ONLY: OWNER ❑ AGENT li- 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 acc ate 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 wit Pertinent provision of the Massachusetts State Plumbing Code and Chapter '142 of the General Laws. PLUMBER-GASFITTER, NAME LICENSE # SIGIIIIFE IMP !�JiC.�F JP JGF n LPGI ❑ CORPC)RAT ON ❑ IF PAP,TN R.SHIP ❑ # LLC #i: COMPANY I'IAI E , E ADDRESS2 ñXJ �'" '� e� CITY ', MO UTV- STATE /-4)'4ZIP 3 TEL 5-65 gqq3 FAX CELL EM E•- "r G1 rzl Z I 0 II Pi 4.4 Z I —1 I 7 I I I I I I I III G7 ti 1 S LU F— U- I I 1 I Cl 1 7- I �. I . I G 1 I C) W r1a En i Iuri I Z 0 I