Loading...
HomeMy WebLinkAboutBLDG-22-005385 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1E - CITY YARMOUTH MA DATE March 25,2022 PERMIT# BLDG-22-005385 JOBSITE ADDRESS 280 OLD MAIN ST OWNER'S NAME CALLAHAN EDWARD P G OWNER ADDRESS CALLAHAN LESLEY A 83 RUFF CIR GLASTONBURY CT 06033 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 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 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© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: BENJAMIN DIAMANTOPOULOS ADDRESS. 25 ANTHONY RD,25 ANTHONY RD CITY W YARMOUTH STATE MA ZIP 026733776 TEL FAX CELL EMAIL bendiamantopoulosangmail.com S310N M31A3N NVId #1IW213d $:33d ❑ ❑ 1I11213d 3E11 SV S3A213S NOIJVOIlddV SIHI oN saA S310N NO1103dSNI 1VNId WINO 3Sl 210103dSNI 210d 30Vd SIHl S310N NOI103dSNI SV9 H9f102I _ MASSACFIUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK R ai- r [� _� CITY AR IM022 MA DATE 4. 2� PERMIT# 21.-S3 F� K B�fTE ADDRESS �(�� Q(,.�� OWNER'S NAM UILIIING RTME�WI\ERADDRESS c� , B By ... rL t�Fi ---- �/ S � TE ` � L� �21� FA): PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIAL E-------- CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑ APPLIANCES-1 FLOORS-4 ssM 1 2 3 4 5 6 7 BOILER 9 10 11 12 13 tA BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR --- FURNACE "---V4 — ______________ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER .1 _ • ROOM I SPACE HEATER ROOF TOP UNIT -- TEST . . UNIT HEATER LINVENTED ROOM HEATER WATER HEATER —`— OTHER INSUR NCE COVERAGE I have a current insurance policy or its substantial equivalent which meets liabili the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA . Y 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 General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER,OP,AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ 3 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a urate 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Lt1 PLUMBER-GASFITTER NAME ;'� it* PT 1 1/1,40-CENSE#/ �, �p SIGNATURE MP IriGF ,1P �! JGF LPGI ❑ CORPORATION❑# PAR NERSHIP❑# Lc l 6,q4-7- Pi(-� � ❑ COMPANY NAME r ADDRESS, ��V j�//�,ly �� / CITY 1/24/f2114 STATE 01- ZIP, TELVf'l of FAX ��93 A CELL EMAIL o . qmo - cam ROUGHGAS II �FEa 'ICpI'd NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES S Yes N THIS APPLICATION SERVES AS THE PERMIT FEE: PERMIT PLAN REVIEW NOTES