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HomeMy WebLinkAboutBLDG-23-000140 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK VII`�' CITY 'YARMOUTH MA DATE (July 11,2022 'PERMIT# BLDG-23-000140 JOBSITE ADDRESS 1135 WEBBERS PATH I OWNERS NAME STOILAS THEODOROS G OWNER ADDRESS STOILAS PANAGIOTA 135 WEBBERS PATH WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO FIXTURES FLOORS—s BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER • COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 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 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 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. 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 (Kevin Decoteau I LICENSE# 16532 SIGNATURE MP©MGF❑JP❑ JGF❑ LPG( ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: I I ADDRESS. 138 Powhatan Rd, CITY (South Yarmouth I STATE MA ZIP 02664 TEL I FAX CELL EMAIL I S310N M3IA3H NYld #IIV 3d $:33d ❑ ❑ 111183d 31-11 SY S3A2i3S NOIiV011ddy SIHI oN saA S310N NOI103dSNI lYNId AlNO 3Sf1 b0103dSNI WOd 3OVd SIHI S310N NOI103dSNI SVO HOflO