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HomeMy WebLinkAboutBLDG-23-002672 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ° CITY YARMOUTH MA DATE November 15,202; PERMIT# BLDG-23-002672 II � JOBSITE ADDRESS 19 SEASIDE VILLAGE RD OWNER'S NAME ALI LISA M TR G OWNER ADDRESS LISA M ALI LIVING TRUST 3108 FRANKLIN ST SAN FRANCISCO CA 94123 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: m 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 1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER • ROOF TOP UNIT TEST 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 ❑ 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❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: OLSEN PLUMBING&HEATING ADDRESS. 357 Hokum Rock Road, CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX CELL EMAIL OFFICEAOLSENPLUMBING.COM x SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F.a`Ni= CITY'+ Tin MA DATE 111L11 2O22- 1 PERMIT# .2_3 7_4,-7 t_ 140 0 22lOB,ITE ADDRESS 11 i OWNERS NAME BU LDIN PARi�IADDRESS . - TELL FAX BY. T E-OR , — -- PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIA N.vii CLEARLY NEW:id RENOVATION:El REPLACEMENT:Li PLANS SUBMITTED: YES0 NO APPLIANCES-1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILERoail I BOOSTER ;----1,---„--� `0 + i l CONVERSION BURNER sM- r� l l" #Y"'""'""""" ) � 1 ^fig , COOK STOVE i - DIRECT VENT HEATER l -- , .. " DRYER - e 3 , �� FIREPLACE drill I: = I FRYOLATOR . _ ! .' I _". E7-- . 1 FURNACE _ . i �.s 1 ,i API _._ 1. f .. --I w GENERATOR " . � _.�._ .� ..w "m -_ - .II �' GRILLE r i I INFRARED HEATER - ( _":...". N ` i" �ik I e I iW LABORATORY COCKS I I° .� IP 1 I, ;., MAKEUP AIR UNIT - I. { I, `l i ' I "` ] ' _I OVEN 1 I . �_ - a _. I " I�.,..;€ I; , ",".�- �� POOL HEATER — " ROOM/SPACE HEATER i j I, P --- 1._ II ROOF TOP UNIT I is r�_1s --r €. r t: i' I - TEST II . - I, i- v I __ UNIT HEATER i tI ,-1-- 1 [— � v UNVENTED ROOM HEATER ,. t if If- r OTHER r1 • € , W is WATER HEATER ! - .. Mil I µ', E r _,,,,..........,,,..[ mil`. ilk i I n ' INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ril NO ELI I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E BOND 0 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 Ej AGENT I, 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 tot -best y o�wledge and that all plumbing work and installations performed under the permit issued for this application will be in compliancr-wi all P in i of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Olsen LICENSE# M10335 S� SIGNATURE MP M MGF El JP 0 JGF I ] LPG! CORPORATION #f 2166 PARTNERSHIP # COMPANY NAME: Olsen Plumbing&Heating ... Hea . " ADDRESS I P.O.Box 2026,357 Hokum Rock Road CITY I Dennis i STATE MA ZIP 02638TEL508-385 5290 FAX[508-385-6963 J CELLI EMAIL E PLC m iEjo. -_