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HomeMy WebLinkAboutBLDG-22-003660 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY YARMOUTH MA DATE December 30,202'1 PERMIT BLDG-22-003660 II-�` JOBSITE ADDRESS 44 STRATFORD LN OWNER'S NAME CHAUSSE IRENE I G OWNER ADDRESS 44 STRATFORD LN YARMOUTH PORT MA 02675-1447 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 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 ❑ 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 LICENSE# 10335 SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP ❑# LLC❑# COMPANY NAME: RICHARD P OLSEN ADDRESS. PO BOX 2026, CITY DENNIS STATE MA ZIP 026385026 TEL FAX CELL EMAIL officena,olsenplumbina.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i?)-4q1 1 1 ,.n ia?'�;, CITYFgayAlaW11120.11._ .,. 1. MA DATEI iLj 3O1Z DZ PERMIT # 22 — 1 Cf JOBSITE ADDRESS �f�) St o � f xc ICtn C OWNER'S NAME I�.�ll.. , ,. ,.13� !,1..e, ._ .,,w IN OWNER ADDRESS �_.R Tag)K'iDZ �JLAU3 'FAX! W a 4 IliN ` OR OCCUPANCY TYPE COMMERCIAL i' EDUCATIONAL RESIDENTIAL , , NT Q ` W _ 1. RLY NEW:7 RENOVATION: REPLACEMENT: (, PLANS SUBMITTED: YES NO LLI c' ❑ LIANCES Z FLOORS—i BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 12 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _,F OVEN i POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST __ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ OTHER , i r.S►tCOO . 5\r\d', r-cYtVC L. et CC r i C t ( - _� INSURANCE COVERAGE _ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES i 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 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 �i Hof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l - — f PLUMBER-G�,SFITTER NAME Richard Olsen LICENSE # M10335 SIGNATURE MP i MGF JP JGF LPGI CORPORATION i # 2166 I PARTNERSHIP J# 0 LLC # COMPANY NAME: Olsen Plumbing & Heating ADDRESS P.O. Box 2026, 357 Hokum Rock Road ' DennisCITY STATE MA ~ ZIP 02638 TEL 508-385-5290 r _ FAX ' 508-385-5963 i CELLI EMAIL \ C C �4. `Q L5 E K ?),A) M 6 1 N C , CD 1i1