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HomeMy WebLinkAboutBldg-22-001990/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK xn c' BLDG-22-001990 ,e1z CITY YARMOUTH MA DATE October 06,2021 PERMIT# JOBSITE ADDRESS 11 WINDSWEPT PATH OWNER'S NAME WESTON DENNIS A G OWNER ADDRESS WESTON SANDRA L P.O.BOX 257 STAATSBURG NY 12580 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 12 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 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 I SPACE HEATER ROOF TOP UNIT TEST 1 , 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 NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY El BOND Cl 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 richard olsen LICENSE# 10335 SIGNATURE MP© MGF 0 JP❑ JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: olsen plumbing corperation inc ADDRESS. 357 Hokum Rock Road, CITY DENNIS STATE MA ZIP 02638 TEL 5083855290 FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES