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HomeMy WebLinkAboutBLDG-22-007485 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK , CITY YARMOUTH MA DATE June 29,2022 PERMIT# BLDP-22-007485 JOBSITE ADDRESS 6 FRANCES HELEN RD OWNER'S NAME REGALBUTI ARMAND TR PERS REP OWNER ADDRESS CIO GEORGE THOMAS&ALICE TRS 17 THATCHER SHORE RD YARMOUTH PORT TEL MA 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© 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 I 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 ❑ OTHER OF 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. 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 ❑ JP❑ JGF 0 LPG! ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: RICHARD P OLSEN ADDRESS. PO BOX 2026, CITY !DENNIS STATE MA ZIP 026385026 TEL FAX CELL EMAIL officeaolsenplumbinq.com T MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,P v'lni 6 _t 7 . a • CITY . �( (� MA DATE • PERMIT# fYCe JOBSITE ADDRESS � rehYl� --� ���1�t_L--..I.�.�,- WNER'S NAME GOWNER ADDRESS r ..,.. I TEL[Z13 - . FAX . _ -.,. TYPE OR PRINT EDUCATIONAL "d RESIDENTIAL ix OCCUPANCY TYPE COMMERCIAL _.log..: CLEARLY NEW:! ° , N 6 ,� RENOVATION:L_a REPLACEMENT:: ,, PLANS SUBMITTED: YES{ ,, APPLIANCES 1 FLOORS 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 1, BOILER BOOSTER ' i. . CONVERSION BURNER I' - ° . COOK STOVE �__ ;,_... F w.,,,._ i DIRECT VENT HEATER DRYER r i_ f I- FIREPLACE FRYOLATORp -.. 9 FURNACE m._ ,. �....,. ' GENERATOR ° GRILLE 1 _.: i.wt - l kW _ �_. INFRARED HEATER �'- LABORATORY COCKS l OVEN _ n POOL HEATER , I, y ? ROOF TOP UNIT - UNIT HEATER WATER HEATER ... ---- -� BuIL w 11 M. III OTHER rr t,.._ IL- IIIIIMiall ' MEM INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 NO 7 1 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L i y 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 i .71 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 t best -jr owledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance-wi all P in i of the Massachusetts State Plumbing Code and Chapter 142 of the �General Laws. _�.. � I fry�4 PLUMBER-GASFITTER NAME Richard Olsen 1 LICENSE#'M10335 _�_._.._. ._. SIGNATURE LPGI 74 CORPORATION.., .2,,,,_ #i 2166 PARTNERSHIP .# 'LLC i :#i COMPANY NAME'Olsen Plumbing&Heating ___.Hokum i T __„__ u__ADDRESS P.O.P0 Box 2026,357 H Rock Road CITY Dennis ...._ _ .: �,_...._ 4Y STATE'MA ZIP 02638 TEL 508 M f l.C. Q� �.- 38 290 .. ..,. FAX 508 385 6963 CELLS EMAIL r2 4N