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HomeMy WebLinkAboutBLDG-22-007473 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 'June 29,2022 I PERMIT# BLDG-22-007473 I I_ JOBSITE ADDRESS 11 MYFIELLE DR OWNERS NAME BOUCHER CHRISTOPHER G OWNER ADDRESS HUET-HEART TRISTYN 11 MYNELLE DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ 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 1 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 0 NO❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ BOND El 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 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RICHARD P OLSEN ADDRESS. PO BOX 2026, CITY DENNIS ISTATE MA ZIP 026385026 TEL FAX CELL EMAIL offce(0olsenplumbing.com S310N M3IA321 NVId #LIW2:13d $:33d ❑ ❑ 111Na3d 3H1 SV S3ALI3S NOIlV3llddy SIHI oN saA S310N NO1103dSNI 1VNI3 A1N0 3Sfl el0103dSNI NOd 30Vd SIHI S310N NOI103dSNI SVD Nona! MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tF� CITY SW:m. d:. CAY + O O MA DATE. .. T # 1 ��Z I����..�:.�,, PERM JOBSITE ADDRESS[ fyl t l I G1y l ki _ :....� . OWNER'S NAME OWNER ADDRESS :, C,L;(* f,l1r Sr i �- 1 f Xw ► EL fl4 Zik.o OGa . FAXI . TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ►� ` PRINT !� CLEARLY NEW: RENOVATION: REPLACEMENT: Et PLANS SUBMITTED: YES NO APPLIANCES - FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1. BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR _ FURNACE GENERATOR GRILLE • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER RECEiVEDi ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER � L - WATER HEATER By:_ ___.— -- • OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 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 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 AGENT 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 t best y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi ? all P in n j of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Olsen LICENSE # M10335 SIGNATURE MP E MGF JP JGF ; LPGI CORPORATION / '# E 2166 PARTNERSHIP #, ` LLC #j COMPANY NAME Olsen Plumbing & Heating ADDRESS P.O. Box 2026, 357 Hokum Rock Road �_ . -.., .' _ _ - CITY Dennis i STATE MA I ZIP 02638 TEL 508-385-5290 FAX 508-385-6963 I CELLL__' EMAIL I C eD,