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Home My WebLink AboutBLDG-22-000999 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 CITY YARMOUTH MA DATE August 23,2021 PERMIT# BLDG-22-000999 "4-1Ili- JOBSITE ADDRESS 20 GREENLAND CIR OWNERS NAME marlene fuentes G OWNER ADDRESS 20 GREENLAND CIR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER , UNVENTED ROOM HEATER WATER HEATER 1 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 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. 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# 15722 SIGNATURE MP El MGF 0 JP❑ JGF 0 LPG] 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: DAVID R MICHALOWSKI ADDRESS. 22 GREENLAND CIR, CITY YARMOUTH PORT STATE MA ZIP 026752183 TEL FAX CELL EMAIL davemichalowskita7.yahoo.com S310N M3IA3a NVId #111A1213d $ 33d El 11 1IWH3d 3H1 SV S3A213S NOI1VOIlddV SIHI oN saA S31ON NO1103dSNl IVNId AINO 3Sf1 d0103dSNI NOd 30Vd SIH1 S310N NO1103dSNI SV0 HJl021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK n �i CITY: 9/f v�n /17�� N r MA. DATE: PERMIT# Z Z- c,`i S � � JOBSITE ADDRESS: 9_D 6/`r'('if1/,o,, l_ C.,rde OWNER'S NAME-"61/,'Ll i /`r.1-k( I GOWNER ADDRESS: 9,v'-<C//"- ( (era'TEL ,- -S�-)AX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL PRINT ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:B"/ PLANS SUBMI I I ED: YES❑ NO 0 APPLIANCES FLOOR-, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER ' —44 CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER ,,,,, FIREPLACE FRYOLATOR ' FURNACE GENERATOR 4 9 GRILLE VI INFRARED HEATER w LABORATORY COCK MAKEUP AIR UNIT ` _ " OVEN RE +� L ° E ® POOL HEATER ' I ROOM 1 SPACE HEATER } i ROOF TOP UNIT Lf i r{)� fi TEST UNIT HEATER BUILDING uLHAK I MEN] I r I u UNVENTED ROOM HEATER w 1- 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?P If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General and tha y signature on this permit application waives this requirement. � CHECK ONE ONLY: OWNER GENT SIGNAT E OF OWNER ORAGENT 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 Gepsra ws. PLUMBERJGASFITTER NAME: /7,.'. :£- /41/(_4() 117L,/J I/,LICENSE#,/'1 —Jr/ SIGNATURE COMPANY NAME:/'1i�c l a/a--✓�//-, /`�► /1ly/hIO 4 ADDRESS: .2 l✓eC r+/,0r . C.rC G� CITY: l,,,nr' n,r �, r'r--T' /STATE: ZIP:/7.6—7 FAX: TEL: — CELL:271/`7,/7 -. EMAIL: der_r/C i+'1.(1, je 4,_./PA.' ( //r (-11 M MASTE I JOURNEYMA ) LP INSTALLER 0 CORPORATION❑# PARTNERSHIP❑# LI_C❑# c /7i9ie_. AD1i2e--.s5 :let,// 4,, /4 i/C-, co C!0 I 7U