G-19-3556 illMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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MA DATE 10n/I 1 X PERMIT# D6- -019 3
JOBSITE ADDRESS S CClap J-c2LCr is Oct OWNERS NAME Recxvtk- ,,{,/bnMin i
GOWNER ADDRESS nti Carr-5t-catlt it rLa ' , uvt, o4g L icps -3S5'6' ]GAx
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION4 REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
APPLIANCES 1 FLOORS BSM 1 2 3 R I 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER warjaisaliiir.
COOK STOVE M. Mill , i ! i • i .
DIRECT VENT HEATER
DRYER
FIREPLACE
innial, i -
FRYOLATORIII I,
FURNACE a, is •
GENERATOR ' NOI,O1—ft .mum imalmaimii'nt
GRILLE
INFRARED
LABORATORY COCKS WI'1•,';i�, 'I�;I�
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MAKEUP AIR UNIT
MAKE In .:f tn•fl
'VO�O,OINO II'SOOONi
POOL HEATER11.11.1=11==. t�
ROOM I SPACE HEATER r-ter i—,�—i��
ROOF TOP UNIT - ��, 1ONO.
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TEST —.. j fl �'��:� ll
UNIT HEATER �('i�l��Oi Il O���
UNVENTED ROOM HEATER 5s LI�;�-sI� 'i�'a:a
WATER HEATER —'� _ ( Ii 1
OTHER ' nn, i
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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 El OTHER TYPE INDEMNITY El BOND ❑
OWNER'S INSURANCE WAIVER:lam 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 El AGENT ❑
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 Richard Olsen LICENSE# M10335 SIGNATURE
MP Q MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 2166 PARTNERSHIP❑# LLC❑#I
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 RE C E 1 V t t`
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DEC 112016 I
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