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Home My WebLink AboutBLDG-22-003561 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE December 28,202'PERMIT# BLDG-22-003561 _ _ JOBSITE ADDRESS 124 PINE GROVE RD I OWNER'S NAME Peter Afouxenides G OWNER ADDRESS 12.411E GROVE RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El 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 1 FIREPLACE FRYOLATOR FURNACE 1 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 1 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 El NO❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY❑ BOND El 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 OF: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 slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'Peter Afouxenides I LICENSE# 132750 I SIGNATURE MP El MGF El JP El JGF❑ LPG'El CORPORATION El#I I PARTNERSHIP ❑# ILLC❑#I COMPANY NAME: 'PETER AFOUXENIDES I ADDRESS. 148 RIVER ST, CITY ARLINGTON 'STATE MA ZIP 024743540 TEL I FAX 1 1 CELL I-_'l EMAIL Iafoux33Womail.com S310N MJIA32i NVld #.UV I d $ :33d ❑ ❑ 111%13d 3H1 Sd S3AHH3S NOI1HOIlddV SIHl oN seA S310N NO1103dSNI 1VNId KING 3Sf11013 dSNI NOd 39Vd SIHl S31ON NO1103dSNl SVD HOfOH ,S7O, OD MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �,--.. MA. DATE:, Ir PERMIT# 2 7 08S(TE A R SS: a L( �'t 6� 1`—c� OWNER'S NAME: /- I oukseehiks - G�m� ly ,j4{,o- _-- L-OWNER Lis. IR ( tier �I it v'l �74 jgELC)} y FAX: _ , Ij U PARTMENTY rV ��CCU'AdC PE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ❑ CLEARLY NEW: .iRENOVATION: ElREPLACEMENT: ElPLANS SUBMITTED: YES ❑ NO Q APPLIANCESZ FLOOR Bsmt 1 —2— 3 4 5 6 7 8 9 10 11 12 13 14 r BOILER BOOSTER (-./), CONVERSION BURNER COOK STOVE DIRECTR VENT HEATER DR FIREPLACE FRYOLATOR FURNACE GENERATOR w GRILLE V� INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER NI ROOF TOP UNIT fi TEST UNIT HEATER 14.3 UNVENTED ROOM HEATER WATER HEATER 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 have 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 Massachusetts rat Laws, and t my signature on this permit application waives this requirement CHECK ONE ONLY: OWNERE5' AGENT ❑ SIGNATURE 0 OWNER OR AGENT 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 applied(' will be In mpllance with all Pertinent provision of the Massachusetts State.Plumbing C ode and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: PCeC XC'<?t {'S LICENSE#32 T 56 SIGNATURE COMPANY NAME: ADDRESS: qs r Ver CITY : AC_I i () 11 STATE: PIA-� ZIP:�� 1 FAX: TEL: CELL: -8 O 1` I ( O3 EMAIL: -t'D U X 3,3 @ 4 MASTER ❑ JOURNEYMAN d LP INSTALLER ❑ CORPORATION ❑# PARTNERSHIP ❑ # LLC ❑ # c m tic. Al Dze-SS . a Qf> x 3,W3 r2 ez