HomeMy WebLinkAboutBLDG-22-005780 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
q6 CITY YARMOUTH MA DATE April 11,2022 PERMIT# BLDG-22-005780
JOBSITE ADDRESS 30 VIOLET GLEN RD OWNER'S NAME GRABOWSKI BOGDAN S
G OWNER ADDRESS GRABOWSKI PATRICIA B 30 VIOLET GLEN RD SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL
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CLEARLY NEW: El 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 1
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 ❑ NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY CI BOND El
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 LICENSE# SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC El#
COMPANY NAME: ADDRESS.
CITY STATE ZIP TEL
FAX CELL EMAIL
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