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HomeMy WebLinkAboutBLDG-23-005214 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t ',b CITY YARMOUTH MA DATE March 22,2023 PERMIT# BLDG-23-005214 S,T> JOBSITE ADDRESS 48 LAKEFIELD RD OWNER'S NAME DIMADAKIS DIMITRIOS G OWNER ADDRESS 48 LAKEFIELD RD SOUTH YARMOUTH MA 02664-0000 TEL L 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 _ FRYOLATOR FURNACE GENERATOR 1 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY❑ 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 LESTER WADE LICENSE# 4569 SIGNATURE MP❑ MGF © JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD,22 CAPTAIN ISIAHS RD CITY COTUIT I STATE MA ZIP 026352702 TEL FAX CELL EMAIL info(a,ccipgenerators.com - 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 TO PERFORM GAS I I t MG WORK CITY If fit,r 6vt r;��. 1- 1' MA. DATE I i PERMIT# JOBSITE ADDRESS `f`11 Et ' tc--.4 OWNERS NAME - 1'c Apt r et.,el et le-r GOWNER ADDRESS SI cc. Moo TEL is - ' _3, s q FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT C>A AR Y .NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO f APPLIANCES 1. FLOORS-8 BSM 1 2 3 4 5 6 7 8 9 10 I 11 12 13 14 BOILER _ _ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE I FRYOLATOR FURNACE GENERATOR e� GRILLE INFRARED HEATER _ LABORATORY.COCKS _ 1 MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 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 MGL Ch.142 YES ® NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OP COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Cap OTHER TYPE INDEMNITY 0 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. CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT i hereby cerfsfy that all due details and information I have submitted or entered regarding this application are true and accurate to the best of knowledge and that all plumbing worry and Installations performed under the permit issued for this application will be in compliance ' all P ofthe o Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C� PLUMBER-GASH l ttk NAME L5+"e r LA/t eft- UCENSE# 4 5t0 SI RE MP❑ MGF® JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME "a6'P_ c nrcrecCe, ri d? o.-j- i? -Lr ADDRESS a3 r`tie fist. CITY Aka.sikpe.,p STATE AM ZIP ( -( 41 TEL 50 T-4-11 — FAX g1/4.)1 A CELL 50g-15 0--g i g EMAIL ce► 644, A fa XL_ I MAR 22 2023 BUILDING DEPARTMENT By -_-----