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HomeMy WebLinkAboutBLDG-22-003901 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY LARMOUTH MA DATE January 13,2022 PERMIT# BLDG-22-003901 41 1 JOBSITE ADDRESS 121 SILVER LEAF LN j OWNERS NAME AGELOPOULOS JAMES L LIFE ESTATE G OWNER ADDRESS AGELOPOULOS DEAN J 1058 ALBEMARLE RD NORWOOD MA 02062 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:0 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 DIRECT VENT HEATER • _ DRYER FIREPLACE 1 _ FRYOLATOR FURNACE • _ GENERATOR GRILLE _ INFRARED HEATER • LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOMISPACEHEATER _ 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 El BOND ❑ OWNERS 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 hereby vanity 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 Matthew scioletti LICENSE# MA SIGNATURE MP 0 MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Scioletti Plumbing and Heating ADDRESS. 58 townhouse terrace.. CITY HYANNIS STATE MA ZIP 02601 TEL FAX CELL EMAIL S310N M3IA321 NV1d #11012:13d $ 33d ID iIWH3d 3H1 SV S3Ab3S NOLLVOIIddV SIHl oN seA S31ON NOI103dSNI 1VNid l lNO 3Sf1210103dSNI 21Od 3OVd SIHl SALON NOI103dSNI SYO HJl021