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Home My WebLink AboutBLDG-22-003563 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j CITY YARMOUTH li MA DATE December 28,202' PERMIT# BLDG-22-003563 t 3� JOBSITE ADDRESS 398 LONG POND DR OWNER'S NAME John Stanley G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ElRESIDENTIAL El 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 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE 1 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# 10335 SIGNATURE MP❑ MGF 0 JP 0 JGF❑ LPG' ❑ CORPORATION❑#I I PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Richard P Olsen ADDRESS. PO BOX 2026, CITY DENNIS STATE !MA I ZIP 1026385026 I TEL FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F_(—{ CITY _....., _. I V_a:' aL�rh_ JCI,( narni)..._.... 1 MA DATE 1212 0121 ;PERMIT# JOBSITE ADDRESS; ion C) pone! Or, is OWNER'S NAME John S r-cy-1 I f . ___,, , GOWNER ADDRESS ! =.._.s.— TEL1 065�C-o U U FAX FAX l___...�. _,_m TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL , PRINT CLEARLY NEW _= RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES; NO APPLIANCES 1 FLOORS-0 6 BOILER BSM 1 2 3 4 5 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE � � DIRECT VENT HEATER 11111 DRYER FIREPLACE MEM FRYOLATOR FURNACE GENERATOR 111111101111101111 GRILLE INFRARED HEATER IIIIIIIIIII LABORATORY COCKS MAKEUP AIR UNIT IMMII OVEN MIII ® — . POOL HEATER ROOM/SPACE HEATER ®11111® ROOF TOP UNIT TEST _ ®®' UNIT HEATER MIIIIIIIIIROMI UNVENTED ROOM HEATER Mintuflimi . WATER HEATER _THER .. O WWWi 11111.111 �i W n_. I have a current liability insurance poll., INSURANCE COVERAGE cy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I i NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND I 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 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 in n I jt of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Praowledge LUMBER-GASFITTER NAME°Richard Olsen �LICENSE# M10335 '�% SIGNATURE MP v MGF RATI PARTN JP JGF LPGI CORPORATION -# 2166 ERSHIP # `LLC a :#! ... Plumbing&Heating __�__. .._ COMPANY NAME: Olsen Plum ingHokum Rock Road CITY Dennis ADDRESS P.O.Box 2026,357 ^ STATE MA ZIP 02638 TEL 508-385-5290 l ( ( �... , F..,. FAX 508 385 6963 CELL , 01 J E ?LU