HomeMy WebLinkAboutBLDG-23-005665 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�6 CITY YARMOUTH MA DATE April 11,2023 PERMIT# BLDG-23-005665
JOBSITE ADDRESS 28 COLBURNE PATH OWNER'S NAME MOORE KERRY I
G OWNER ADDRESS 28 COLBURNE PATH WEST YARMOUTH MA 02673 I TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO El
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 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 ❑
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 El MGF 0 JP El JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC El#1
COMPANY NAME: BENJAMIN DIAMANTOPOULOS ADDRESS. 125 ANTHONY RD,25 ANTHONY RD
CITY W YARMOUTH STATE MA ZIP 026733776 TEL
FAX CELL EMAIL bendiamantopoulosna pmail.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 I.JNIFORMU1 APPLICATION FORA ERIUlET TO PERFORM GAS FITTING WORK
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11 JOBSIT 4D RFSS C� f �hF, NAME � f'' '' BIER D RESS � � � TEL l �/ 2j Zjl7-1 /------------------/(46)6))
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B 1{ E J u T. �IC TYPE COMMERCIAL _ EDUCATIONAL I— RESIDENTIAL
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CLEAF, ' NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ] NO Eri
i
APPLIANCES FLOORS-4 BSIv1 1 2 3 1 5 6 7 8 9 10 11 12 •I; 1
BOILER —`--;
BOOSTER 1
CONVERSION BURNER
COOK STOVE '
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYC)LATOR
FURNACE f
GENERATOR
GRILLE I J INFRARED HEATER 1
LABORATORY COCKS {�
MAKEUP AIR UNIT T I
OVEN •
POOL HEATER •
ROOM / SPACE HEATER ____~
ROOF TOP UNIT
TEST _
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL. Ch. 142 YES ItlO [�
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE 9 ECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY I I BOND I I
• 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 ❑ 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 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 inent provision of the
Massachusetts State Plumbing Code and Chapter .I42 of the General Laws.
PLUMBER-GASFITTER NAME kai2) LICENSE# / SIGNATURE
MP !.- GFEr-CPGI l CORPORATION ❑#f } PARTNERSHIP ❑ # LLC l #i
COMPANY NAME Mg7L--r P A / 4, RESS Z_____ /�` /L1T */ L/ c
CITY // i4 l./ 7 W- STATE/tt, 1 ZIP (5 ` TEL • C •-, •$<'
FAX CELL EMAIL - C e)
eq ng>
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