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HomeMy WebLinkAboutBLDG-21-004877 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK jiff;;;:.:'; CITY YARMOUTH MA DATE March 01,2021 PERMIT# BLDG21 004877 JOBSITE ADDRESS 56 PLEASANT ST OWNER'S NAME SKAFF KARAM D TRS G OWNER ADDRESS SKAFF DONNA M TRS 675 LONGBOAT CLUB RD UNIT 23A LONGBOAT KEY FL TEL 34228 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El 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 1 • 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 0 LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: Olsen Plumbing&Heating ADDRESS. PO BOX 2026, CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES