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HomeMy WebLinkAboutBLDG-22-000906 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � _` � CITY YARMOUTH MA DATE August 17,2021 PERMIT# BLDG-22-000906 l JOBSITE ADDRESS 22 GREENLAND CIR OWNER'S NAME david michalowski G OWNER ADDRESS 22 GREENLAND CIR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 'David Michalowski LICENSE# 115722 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: (DAVID R MICHALOWSKI ADDRESS. 122 GREENLAND CIR, CITY YARMOUTH PORT STATE MA ZIP 026752183 TEL 1 FAX CELL 1 EMAIL ldavemichalowski(a vahoo.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 UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V _ CITY: AP/'7 Avrh,e, MA. DATE ,FX 7/•1— I PERMIT# JOBSITE ADDRESS". �rPE.-, Lror,1 Cir C/e OWNER'S NAME: I�'I' h- G OWNER ADDRESS:02-v2 lir Atki/.a.-, 1 Cir C le TEL:7 7'/9`J/7s FAX cTYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRIIVT CLEARLY NEvgp RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 1/41 APPLIANCES1 FLOOR-, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER e CONVERSION BURNER - COOK STOVE DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE tut INFRARED HEATER et) LABORATORY COCK c MAKEUP AIR UNIT 'NI OVEN RECEIVED POOL HEATER ROOM/SPACE HEATER AJG 17 2021 -4 ROOF TOP UNIT csE TEST UNIT HEATER BUILU NUDE AK IVIENT t� UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO*1.3 If you have checked Xja,please Indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 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 CHECK ONE ONLY: OWNER AGENT 0 SIGNATURE OF OWNER ORAGENT hereby certify that all of the details and information I have submitted(or entered)regarding this appkcation 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: �./OZ4&( /J9"c.L,,0/0,,,J k., LICENSE /n-157SIGNATURE COMPANY NAME:'/C/.c,to f�- ,y/�,���,,y ADDRESS: .2-2- t^'rn-1-+ 4on c c CITY: yArsi,e�ti� v f STATE: /1//0 ZIP: a.76--7) FAX TEL: CELL77% /i1V7c1 7 EMAIL GIA,✓eri,c.4 41.dfic ► yh de) , CO`M MASTER Q/JOURNEYMAN gr LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# E 09M/22-SS are,v C /ow J'k r- 07,31 - C.�i�