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HomeMy WebLinkAboutBLDG-22-000957 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE (August 19,2021 I PERMIT# BLDG-22-000957 I JOBSITE ADDRESS 715 ROUTE 6A OWNER'S NAME APANDIDA LLC G OWNER ADDRESS CIO ROYAL II RESTAURANT&GRILLE 715 ROUTE 6A YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 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 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 ❑ OWNERS 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 at 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 at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME richard olsen LICENSE# 2166 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPG( 0 CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: olsen plumbing corperation inc ADDRESS. 357 Hokum Rock Road. CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX CELL EMAIL S31ON M3IAR1 Ndld #IIW213d $ :33d 111V:13d 3H1 SV S3Aa3S NOIiV011ddd SIHL oN se), S310N NO1103dSNI 1VNIJ AlNO 3Sfl 2I0103dSNI 803 3OVd SIHL S3lON NO1103dSNI St/0 H0f102J