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HomeMy WebLinkAboutBLDG-23-000093 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK jIiy' CITY YARMOUTH MA DATE July 07,2022 PERMIT# BLDG-23-000093 JOBSITE ADDRESS 658 ROUTE 28 OWNER'S NAME 'PHOENIX II LTD PARTNERSHIP G OWNER ADDRESS CIO SHEPHERD AND GOLDSTEIN 316 MAIN ST WORCESTER MA 01608-1553 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR 4 FURNACE 1 GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 1 POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER 3 OTHER DESCRIPTION:steam table 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©MGF❑JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: BENJAMIN DIAMANTOPOULOS ADDRESS. 25 ANTHONY RD,25 ANTHONY RD CITY W YARMOUTH STATE MA 1 ZIP 026733776 TEL FAX CELL EMAIL bendiamantopoulosna.gmail.com S310N MRIA321 NVld #1I Wd3d $:33d ❑ ❑ 111VEd 3H1 SV SAS NOI1VOIlddV S11-11 oN saA S31ON NOI103dSNI 1VNId AlNO 3Sl 210103dSNI 2103 3OVd SIHI S3 LON N01103dSNI SVO HOflO I algd.d.J 7__ _ MASSACHUSETTS UNIFORM APPLICATION FOR PER IT TO PERFORM GAS FITTING WORK :-' 7 --5f I V E i F - 17-Y � ��..1"W J 1. (/! IM4A DATE G� pF haL1 - a 93 am _ I ..11.1L 06 W T AD RE.SSE-35- P---T 21 OWNER'S NAME / BulL .': ' DENAc I ` NI,D TRESS TEL FAX r v PRINT TYPE COMMERCIAL EDUCATIONAL IliRESIDENTIAL❑ CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES NO❑ APPLIANCES FLOOR., BSM 1 2 3 1 5 6 7 8 9 10 '11 12 13 1 BOILER BOOSTER CONVERSION BURNER I COOK STOVE —� _ i DIRECT VENT HEATER / i DRYER, 1— FIREPLACE i FRYCiLATOR L FURNACE 1 GENERATOR GRILLE _IINFRARED HEATER —� __ LABORATORY COCKS i-�� MAKEUP AIR UNITL (...) F __ OVEN 7 _ I POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT ____' TEST _ . UNIT HEATER .._..... __ .. _... UNVENTED ROOM HEATER [ER WATER HF1 T OTHER -04J(1)T VI- 1.10_174-v �" 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 OF COVERAGE 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 j Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑SIGNATURE OF OWNER OR AGENT `ii, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac urate to the best of my knowledge `R and that all plumbing work and installations performed under the permit issued for this application will be in compliance h all Pertinent provision of the .< Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. 41 PLUMBER-GASFITTER I ME ��' - .> LICENSE## l 3/ SIGNATURE MP 1 MC;F JP JGF PGI ❑ CORPORATION 4 E_ COMPANY NAME //oey&.-r /9� f ❑ PP.RTN�R/�S-H,�IP)�❑7#—�/,1�/ �(��C y❑��; l G 1 ADDRESS � /1 v G "I OL`-' T' /`� CITY Y'4tMo u� STATE MA- ZIP 0 3 TEL gO FA?; CELL EMAIL CSf mq( ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FILIAL INSPECTION NOTES Ye5 No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT # PLAN REVIEW NOTES