HomeMy WebLinkAboutBLDG-22-002736 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY 'YARMOUTH 11--- I MA DATE November 12,2021 PERMIT# BLDG-22-002736
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JOBSITE ADDRESS 195 ROUTE 6A I OWNER'S NAME IHAGOPIAN JESSE R
G OWNER ADDRESS 'HAGOPIAN REBECCA JEAN 95 ROUTE 6A YARMOUTH PORT MA 02675 I TEL I 1
TYPE OR OCCUPANCY TYPE
PRINT COMMERCIAL❑ RESIDENTIAL El
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 1
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
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 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 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.
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
MP 0 MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION❑#LICENSE# 2166
SIGNATURE
COMPANY NAME: olsen plumbing corperation inc PARTNERSHIP 0# _LLC ❑#��
ADDRESS. 357 Hokum Rock Road,
CITY Dennis
STATE MA ZIP 02638 TEL 5083855290
FAX CELL
EMAIL
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