HomeMy WebLinkAboutBLDP-17-003850 y
s" MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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VW CITY +h) . 1IarMc)u 4'h MA DATE 1I71Ii1 IPERMIT# As-mean a
JOBSITEADDRESS S9)0 W."Grmoolk 2,4 OWNER'S NAME I buret
P OWNER ADDRESS TEL FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:E PLANS SUBMITTED: YES❑ NO
FIXTURES 1 FLOOR–. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1111.1111110.1.7111.....1111.
DEDICATED SPECIAL
DEDICATED GREASE SYS TEM STE SYSTEMLit I .ilMalliiin MEIN. 'g = M
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GRAY WATER SYSTEM tea
, IN '1111 4M,a
DEDICATED WATER RECYCLE SYSTEM r
DISHWASHER
DRINKING FOUNTAIN • wanil
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FOOD DISPOSER nwsaswssss• =rn
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FLOOR I AREA DRAIN _
•• DRAIN. •. sass-si. ......m.
LAVAT
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SHOWER STALL
TS0ERILVEITCE/MOP SINK _ O
URINAL WASHING MACHINE RCONNECTION s
WATER HEATER ALL TYPES iM i
WATER PIPING
OTHER 1
PIPPLmo_____'_ ,a
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES O NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 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 Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT /'
I hereby certify that all of the detafs and Information I have submitted or entered regarding this application are true-.••ac - -te t. a bee edge
and that all plumbing work and installations performed under the permit Issued for this application will be in ww e: nth,,,e:rtinen,r.� o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ``
PLUMBERS NAME RICHARD OLSEN LICENSE# M10335 SIGNATURE
MPO JPO CORPORATION O# 2166 PARTNERSHIP 0# LLC D#
COMPANY NAME OLSEN PLUMBING&HEATING ADDRESS 357 HOKUM ROCK ROAD
CITY DENNIS STATE MArr ZIP 02638 TEL 508-385-5290
FAX 508-3856963 CELL EMAIL OX IrR (3 O1cc' piorvlbtn • Coll
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t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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ill-= CITY TV t y1 n 11 f k I it
DATE 1 / 71 I/ 1 PERMIT#ga /77709
JOBSITEADDREJJSS 5 R n W • \lnYmn111 A OWNER'S NAME T. Lamm
GOWNER ADDRESS tt TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIALE EDUCATIONAL El .RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YESO NO[ '
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER i;
BOOSTER it ll; it I
CONVERSION BURNER h
COOK STOVE
DIRECT VENT HEATER j it 11 I. f
DRYER Ii r
FIREPLACE
j i.
FRYOLATOR 'i IL i 1 lI
FURNACE I. Li ---- ',
GENERATORi IL
GRILLE �� d li li ii i I � II
INFRARED HEATERI j, iG r It
LABORATORY COCKS
MAKEUP AIR UNIT I 1.
OVEN I „ II F 1 i i 4 L a
POOL HEATER
ROOM I SPACE HEATER _ I II i
ROOF TOP UNITI I l I - i Ii i IL I .- I
TEST - 1
UNIT HEATER i „ II i i 1
UNVENTED ROOM HEATER iL t I _ h I __a
WATER HEATER L . I
OTHER I v
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l
,• ; I II , _ _ I I_ _
I _ I
P INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY C] 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 Laws,and that my signature on this permit application waives this requirement.
•
CHECK ONE ONLY: OWNER a AGENT IN
SIGNATURE OF OWNER OR AGENT i i
I hereby certify that all of the details and information I have submitted or entered regarding this application are true:-• accur. - to tst o p' y. edge
and that all plumbing work and installations performed under the permit Issued for this application will be in co ••lance • - all P , ent p4 e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —...I1110.
,
PLUMBER-GASFITTER NAME Richard Olsen LICE •E# Ml'-e. SIGNATURE
MPC] MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 2166 PARTNERSHIP❑# _,__. _ LLC❑#
COMPANY NAME: Olsen Plumbing&Heating ADDRESS P.O.Box 2026,357 Hokum Rock Road
CITY Dennis STATE MA ZIP 02638 TEL 508-385-5290
FAX 508-385-6963 CELL EMAIL O Rk 1(e (2) 0 Icy,I l ll IvIb1 n cy . C Ow-1
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