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HomeMy WebLinkAboutBLDG-23-004082 S\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY YARMOUTH MA DATE January 24,2023 PERMIT# BLDG 23 004082 JOBSITE ADDRESS 9 VICTORY LN OWNER'S NAME Todd Olson G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 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 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 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❑ LPGI 0 CORPORATION❑#I I PARTNERSHIP ❑# LLC ❑# COMPANY NAME IBENJAMIN DIAMANTOPOULOS I ADDRESS. 125 ANTHONY RD,25 ANTHONY RD CITY IW YARMOUTH I STATE MA ZIP 1026733776 I TEL I I FAX I CELL I I EMAIL IbendiamantoDoulos(@,omail.com I 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 ,Orive "� MASSACHUSETTS UNIFORM APPLICATION FOR A FERMI TO PERFORM GAS FITTING WORK �.'`=L-n—.,gi CITY i�'v ` U MA DATE ( } S 2-2 PERMIT# 7-1 `'(OFZ ;°. J JOBSITE ADDRESS WNER'S NAME 0 C el / °Dv GOWNER ADDRESS TEL FAX TYPE OROCCUPANCY TYPE COMMERCIAL EDUCATIONAL PyNT ❑ ❑ RESIDENTIAL©� CLEARLY NEW:❑ RENOVATION: Imo" REPLACEMENT: PLANS SUBMITTED: YES NO❑ APPLIANCES 1. FLOORS-4 BSIu1 1 2 3 4 5 6 7 8 9 10 11 12 •13 1a BOOSTERBOILER CONVERSION BURNER COOK STOVE 1 ill ■ f DIRECT'VENT FIEATER 11 DRYER FIREPLACE i FRYOLATOR LABORATORYFURNACE GENERATOR GRILLE i INFRARED HEATER iii r. 111 111 1 MAKEUP AIR UNIT ____I OVEN -_____l ROOM!SPACE HEATER 1 ROOF •' UNITILDf TEST . UNIT HEATER , UNVENTED ROOM 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 OF COVERA NECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ i OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the fMassachusetts General Laws,and that my signature on this permit application waives this requirement. I. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT -1, I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate to the best of my knowledge `-1. and that all plumbing work and installations performed under the permit issued for this application will be in compl' nc th all Pertinent provision of the Massachusetts State Plumbing C de and Cha er 142 of the GeneJOf'O al Laws., j PLUMBER-G SFITTE 1\1AMEen !??a rA a a � ICEAE SIGNATURE MP I MGF❑ JP �GF LPGI Eli CORPOP TION❑ Pk ,TNERSHIP+ �'❑it LLC❑It COMPANY N ME /-1D6m-r2---r e-friADDRESS !rJ /lI ! I °I) CITY Lit& 114 0 ti Tb4 STATE MA- ZIP 0 7 TEL` b g 360 3-"t l FAX CELL EMAIL ) _61. O U Ca c lobo )n ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT i PLAN REVIEW NOTES