HomeMy WebLinkAboutBLDG-19-000400 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
- CITY YARMOUTH MA DATE July 19, 2018 PERMIT# BLDG-19-000400
JOBSITE ADDRESS 72 SILVER LEAF LN OWNER'S NAME GOLEBIOWSKI STEVEN M
G OWNER ADDRESS GOLEBIOWSKI SUSAN E 18 WETHERELL STREET WORCESTER MA TEL
01602
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
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CLEARLY NEW CI RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESE NOD
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
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 NOD
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ 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 Stephen Roberts LICENSE# 5104 SIGNATURE
MPD MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: STEPHEN W ROBERTS ADDRESS 17 LAKE DR,
CITY PLYMOUTH STATE MA ZIP 023605647 TEL
FAX CELL EMAIL
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