HomeMy WebLinkAboutBLDG-23-2221 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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. �IrN1Clt)CY1 9U 1" I MA DATE 101 ;I zOZZ PERMIT# zZ z
JOBSITE ADDRESS OWNER'S NAME nr1�l;-►r(W- C
OWNER ADDRESS
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TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL RESIDENTIA
PRINT
CLEARLY NEW:
RENOVATION: REPLACEMENT:fic I
PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS--+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1,
BOILER
BOOSTER a � _ .
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CONVERSION BURNER " I r
COOK STOVE I r—"
DIRECT VENT HEATER "
DRYER
FIREPLACE '
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FRYOLATORanim 11111 `
FURNACE I ,___. .,__ ,______,nj ,
GRILLE
INFRARE
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UNIT HEATER
UNVENTED -•• i - r I C I me....,.„,µ 7 ...,.
WATER HEATER ' l'
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SURANCE COVERAGEI 1` I a _::
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I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES
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I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW NO
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 Laws,and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ii AGENT ,r.
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
and that all plumbing work and installations performed under the permit issued for this application will be in compliance-wi all P . owledge
in
Massachusetts State Plumbing Code and Chapter 142 of the General Laws, i of the
PLUMBER-GASFITTER NAME Richard Olsen %�4
__.- LICENSE# M10335
MP 11 MGF SIGNATURE
JP JGF 0 LPG'fl CORPORATION #12166 1.PARTNERSHIP 71# i LLC M I#I
COMPANY NAME: Olsen Plumbing&Heating " " "
;ADDRESS P.O.Box 2026,-- Hokum Rock Road —,
CITY Dennis
STATE MA ZIP 02638 TEL 50
18-385-5290 -
FAX 5 80 385-65 963 CELL " -- m
:EMAIL C �L E (�)
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