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HomeMy WebLinkAboutBLDG-22-003584 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK A° qr CITY YARMOUTH MA DATE December 28,202'PERMIT# BLDG-22-003584 JOBSITE ADDRESS 149 STATION AVE OWNER'S NAME Jessica croker G OWNER ADDRESS 149 STATION AVE SOUTH YARMOUTH MA 02664-0892 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID 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 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ 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 Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Olsen LICENSE# 10335 SIGNATURE MP©MGF❑JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RICHARD P OLSEN ADDRESS, PO BOX 2026, CITY DENNIS STATE MA ZIP 026385026 TEL FAX CELL I EMAIL offcea,olsenplumbinq.com S310N M3IA3H NVld #JI1Vf3d $ :23d ❑ ❑ IIW83d 3H1 SV S3A83S NOIIVOIlddd SIHI oN saA S310N N01103dSNI 1VNId AlNO 3Sfl H01.03dSNI HOd 30Vd SIHI S310N NOI1.D3dSNI SVO HOfOH , r .ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK R ►T' e i r MA DATE Cl- IC ' tom;G�� CITY � 1 U� �:C,�Y�C)I�CYl IL II) .Z j PERMIT # Cote.c_. 1 '�JSIT ACDRESS. I( I S Cj 4U1� V tie OWNER'S NAMEi3csrci _ . EU l L D t NAtivNIVI v.vEADDRESS TEL ZS —1O\ , I ID(.P . FAX - .: ,. .m:... .:::: AX : PRINT OCCUPANCY TYPE COMMERCIAL ' EDUCATIONAL RESIDENTIAL CLEARLY NEW.f ' RENOVATION: L i REPLACEMENT: 0 PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER T. 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 -II - ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES l NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 i AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have subrnitted 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 of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Olsen LICENSE # M10335 SIGNATURE MP MGF JP °--.1 JGF LPGI r®° CORPORATION � # 2166 PARTNERSHIP #I LLC # COMPANY NAME: Olsen Plumbing & HeatingADDRESS P.O. Box 2026, 357 Hokum ~Rock Road CITY Dennis STATE MA ZIP 02638 TEL 508-385-5290 9 _FAX 508-385-6963 , CELL ... EMAI L�...:.O 1` j C C. CO: 0_�...E. f v_ ?1,-U 0-)6 l._N . L hf