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HomeMy WebLinkAboutBLDG-23-005208 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V1eY1W-:(' CITY YARMOUTH MA DATE March 22,2023 PERMIT# BLDG-23-005208 h� T <., JOBSITE ADDRESS 9 HOMER AVE OWNER'S NAME CHRISTINA DEMETRIOU G OWNER ADDRESS 9 HOMER AVE SOUTH YARMOUTH 02664-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: [I RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 111 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 I 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 ❑ NO❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSJRANCE POLICY ❑ OTHER OF INDEMNITY CI 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 signatu-e 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 enterec 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 GEORGI VARGOV LICENSE# 16972 SIGNATURE MP❑ MGF El JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP El# LLC ❑# COMPANY NAME: IVARGOV MECHANICAL LLN ADDRESS. 28 WITCHWOOD RD, CITY (SOUTH YARMOUTH STATE Ma ZIP TEL FAX 1 CELL EMAIL vargov.mechanical(a.gmail.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 PERIMTO PERFORM GAS FITTING WORK 0 iii : ,c v n 'C P. ! 1�>'•r�• 1! II • L. MA DATE ()..z/z3 __.. JOBSITEADD S$ 6) V a\M o C 3\Ve OWNER'S NAMECi1fiSt 14a D*wtD-fr;DU ' I, MAR eVaDR Ss o P r FAX \ie TEL508- 9014-053c( FAX EDUCATIONAL ❑ RESIDENTIAL Ea � "4 N��1,PANttItrTYPr COMMERCIAL 0 1 r CLEARLY NEW: RENOVATION: ."i REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 APPUANCES 1 FLOORS-• BSIi 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 GRILLE INFRARED HEATER �■■■■■ LABORATORY COCKS ■■����■�, MAKEUP AIR UNIT OVEN == IIIII POOL HEATER � — ROOM!SPACE HEATER ROOF TOP UNIT Ill TEST �■� UNIT HEATER _—��� UNVENTED ROOM HEATER ill II III WATER HEATER i OTHER INSURANCE COVERAGE I have a current liabiliyinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES © NO 0 I IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 0 SIGNATURE OF OWNER OR AGENT n are true and accurate to the best of my knowledge I hereby certify that all of the detals and information I have submitted or entered regarding this app�atio and that all plumbing work and installations performed under the permit Issued for this appticaSo 1 MI be in compliance with ail Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME GiQO Cq tV C1fty)V uCENSE#P U 6 q 12 M SIGNATURE MP© MGF❑ JP❑ JGF❑ LPG!❑ ' CORPORATION❑# PARTNERSHIP El# LLC❑# COMPANY NAME V P 4 V I.1,Lv41 A.v r LkADDRESS >a Lk;,-t(L&.war-)6 k CITY S 0U'-tk M.V .ru k STATE A ZIP C 1bh4 TEL FAX CELL Lk -),k). 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