The URL can be used to link to this page

Home My WebLink AboutBLDG-22-005981 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _ MA DATE April 19,2022 PERMIT# BLDG-22-005981 1 CITY YARMOUTH 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 PRINT ❑ RESIDENTIAL GI CLEARLY NEW: ❑ 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 1 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/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 I LICENSE# 110335 J MP ElMGF ElJP❑ JGF❑ LPGI ElCORPORATION 0# I SIGNATURE PARTNERSHIP ❑#I ILLC ❑#I ! COMPANY NAME: !RICHARD P OLSEN I ADDRESS. PO BOX 2026, CITY 'DENNIS I STATE !MA I ZIP 026385026 TEL FAX 1 I CELL I EMAIL office4olsenplumbinq.com .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK y r s ig— 177 c, (1r M ufiY9 . — k = CITY MA DATE f 120Z4 JPERMIT# JOBSITE ADDRESS' C� S' Q�, VII (a(� !OWNER'S NAME GOWNER ADDRESS ' _..... TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL_ EDUCATIONAL PRINT RESIDENTIAL CLEARLY NEW a RENOVATION:' REPLACEMENT:14 PLANS SUBMITTED: YES NOS APPLIANCES 1 FLOORS BSM 1 2 3 4 i-5 6 7 8 910 11 12 13 14 BOILER 1 ... BOOSTER 1 .. .... 1 P CONVERSION BURNER - E __. COOK STOVE . : DIRECT VENT HEATER _ =' DRYER .. ., FIREPLACE I FRYOLATOR —t — . .` _ U` FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN r .POOL HEATER .. .. ROOM/SPACE HEATER - ,— ROOF TOP UNIT ----" TEST . :_. 3. UNIT HEATER ` . UNVENTED ROOM HEATER - l= WATER HEATER ci OTHER ii I have a current liabilityinsurance policyINSURANCE COVERAGE or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ` ; �.a. I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ; iM OTHER TYPE INDEMNITY ' BOND 1_ 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 -'�' 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 ,q knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance-wi all P inpn i of the p 4 Massachusetts State Plumbing Code and Cha ter2 of the General Laws. 1 �' PLUMBER-GASFITTER NAME I Richard Olsen _ W / LICENSE# M10335 SIGNATURE MP ... MGF JP JGF LPGI' CORPORATION # 2166 PARTNERSHIPS# FLLC' #'r COMPANY NAME: Olsen Plumbing&Heating µ. 1 . ''ADDRESS P.O.P 0 Box 2026,357 Hokum Rock Road CITY Dennis _ ... _.. STATE: MA ZIP 02638 TEL 1 508 385 5290 � - e� s l FAX 508 385 6963 CELL �.... EMAIL (} 1 ACC QL.5 J Nc .c0�.-. .. µ ..�