HomeMy WebLinkAboutG-14-613 1 ,.z
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�,a -, �2=; CITY: 1-4 J.+ y v r/h(,,.-Nl. MA DATE/9 "/9 -/- PERMIT# �1/'"���
JOBSrTEADDRESS•�TP,orfn.r/rtt ferr,'o i/.1 r OWNER'S NAME 1it Al2)vnn r
G OWNER ADDRESS: ref ,a P al TEL 77 I,PJCSSDPFAX:
TYPE OR OCCUPANCY TYPE COMMERCIALa EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENTZD PLANS SUBMITTED: YES 0 NOS)
APPLIANCES? FLOOR 1 Ssmt 1 1 1 2 3 4 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14
BOILER I I I _
BOOSTER I I
CONVERSION BURNER - I I 1 I 1
COOK STOVE I 1 I I 1 1 I I 1
DIRECT VENT HEATER 1 1
DRYER I 1
FIREPLACE I J
FRYOLATOR I 1 I _
FURNACE ' I I 1 (/) I I I 1
GENERATOR I I 1 I 1 1
GRILLE I I I -
INFRARED HEATER I
LABORATORY COCK I . I I I I
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER I
I ROOF TOP UNIT
TEST nn I I_
tuNv,ZNtED ObdHEATM I I
. �DECa I I
19201-3 1
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BUILDING 0 /Fr ` INSURANCE COVERAGE
I h• - -- _. _ e policy or its substantial equhralent which meets the requirements of MGL Ch.142 YESS,No 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POUCY_E OTHER TYPE INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAVER: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
hereby cer y 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 instflations 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. /�
PLUMBERIGASFIIIbRNAME/QL'to( A Zici/eta/l� i LICENSE#/5 Z%- ��SSIIGGNNATUTURE
COMPANY NAME:/ iko 1/Wflti threryi/km4,7 ADDRESS: (77 Al. 22/x/* ,et
CITY: C/.g/not-I-A STATE:///? ZIP: (2,7-c(4/ FAX
TEL Vcifi a 6-7 CELL: '—
MASTER 0 JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0-# PARTNERSHIP 0# LC 0
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°UGHGASLNOTES T11LSPAGE FOR INSPECTOR USE ONLY FINAL JNSPucci ONNOTES
Yes No
THIS APPLICATION SERVES AS TI IE PERMIT ❑ ❑
FEE: S PERMIT •
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PLAN REVIEW NOTES
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- 'COMMONWEALTH OF MASSACHUSETTS
.?;.../.
t;, DIVISION OF PROFESSIONAL UCENSURE-BOARD OF
PLUMBERS AND GASFITTERS
LICENSED AS A MASTER PLUMBER
- -ISSUES THE ABOVE LICENSE TO:
DAVID R MICHALOWSKI 3
p
'53' CAPT LOTHROP RDI
S YARMOUTH MA 02664-0000_
15722 05/01/14 194565 `�i
a LICENSE NO t". ‘37.1 EXPIRATION DATE,a"?.SERIAL NO.
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Fold,Then Detach Along All Perforations
al
COMMONWEALTH OF MASSACHUSETTS l 1
'- DIVISION OF PROFESSIONALLICENSUREI BOARD OF
PLUMBERS AND GASFITTERS
LICENSED AS A JOURNEYMAN PLUMBER)
ISSUES THE ABOVE LICENSE TO: f
DAVID R. MICHALOWSKI
56 SE' LOWER LN "
NI'MAPS! -IELD MA 02050-5619
• ^00018 05/01/14 177414 1 '
LICENSE NOWCI.It'.EXPIRATION ,JflDATESERIALNO-
a. if..
Fold,Then Detach Along All Perforations. -
' COMMONWEALTH OF MASSACHUSETTS
$_ ` DIVISION OF PROFESSIONAL LICENSURE
m.&.v',, " eBOAF07OF. . ,
SHEET,.METAL WORKgS'; ` °
k u%'i e3¢ I ;.A,
$� �, ISSUE$�,THE FOLLOWINCsL°CENSE 4,',, °I: s
AS,Ai4OURNEYPERSON UNRESTRICTED"''
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per. c@, $
DAVIZiR MICHALOWSKI2..ii.dg
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64 NORTH DENNIS RDe,"t-.i. \,t w
;YARMOUTH , ,, s MA. 02664-1020
2030 1-07128/15 stAt73391