HomeMy WebLinkAboutBLDP&G-20-001643 #21 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=='•— CITY j ar m Q ul MA DATE 10020/j Cf !PERMIT# t"--i9/a- d (,
JOBSITE ADDRESS �11 D0.v_ ktie, '/( 6A I OWNER'S NAME; t)O t
POWNER ADDRESS! 1 TEL 1 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 3/
PRINT CLEARLY NEW:E RENOVATION:D REPLACEMENT:si PLANS SUBMITTED: YES D NOD
FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BATHTUB ___ �" _ y i
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CROSS CONNECTION DEVICE r� ' r •----i'- -
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DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM -- -1'?- - '
DEDICATED GREASE SYSTEM _ _rMiiiiiiMIMMIIIIIIII IIIIIIIIIIIIII _ ___ '__TM f
DEDICATED GRAY WATER SYSTEM - I
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DEDICATED WATER RECYCLE SYSTEM '�
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INTERCEPTOR(INTERIOR) M____ jig-7 imiumum _ 1.01 .1-7---.1._ 77, ____,
KITCHEN SINK ' 1
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ROOF DRAIN 0 _,
____, ,_____,, - ,- MN_ - _
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TOILET
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WASHING MACHINE CONNECTION MN MINIMINIMINMAINial—fmninial....1
WATER HEATER ALL'TYPES MO______ __ _ErE______,1 2 II=
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 7 NO !�, /
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW y�v(/
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND Q
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapfdr 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER J 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 acc e th f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co e - ovisio e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .--/--1'''
PLUMBER'S NAME j Richard Olsen LICENSE# M10335 ATURE
MPD JP7 CORPORATION a[ # 2166 PARTNERSHIP)#t rLLCO#J I
COMPANY NAME Olsen Plumbing&Heating 4 ADDRESS P.O.Box 2026.357 Hokum Rock Road
CITY I Dennis STATE MA ZIP '02638 ---; TEL 508.385-5290 1
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FAX 508-385-6963 3 CELL EMAIL i I
T MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`:s 4�, � CITY 1 'V V , y(x Cyr 0 0 44n 1 MA DATE j CI 1 ZO i 1 G' PERMIT#j
JOBSITE ADDRESS 2_1 (1(>Lk P- yr 6 A OWNER'S NAME 1 P. gn pa
GOWNER ADDRESS I 1 TEIl PAX!
TYPPiErOR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL �' RESIDENTIALE
CLEARLY NEW: RENOVATION: _ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS 1 2 3 4 6 i 7 8 9 10 11 13 14
BOILER ' j
BOOSTER w
CONVERSION BURNER �7
COOK STOVE _ � - I a _ ; __._.
DIRECT VENT HEATER �'—`-7E-1 ��
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DRYER I'� —I is i •_ �i
FIREPLACE — �`: — �_ __-_.-i_
FRYOLATOR -__J i_ i T; __i ,;
FURNACE i!: —�— _
GENERATOR ®��� _ 1 _i
GRILLE �W.1_11M11_,WIMI ®MINON______ _
INFRARED HEATER cMI NIIIMN — ;M' ; _ ---7,
LABORATORY AIRY COCKS .' _ _ ®_ � I
MAKEUP AIR UNIT
POOL HEATER
1====i+11 EN- ' III _Mili-------
ROOM/SPACE HEATER l MIMIN WINIM _ Min--7
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ROOF TOP UNIT __
TEST _— j ;
UNIT HEATER __ �; — �_
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UNVENTED ROOM HEATER _ • : �
WATER HEATER
OTHER _ —� i
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INSURANCE COVERAGE _
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I /!NO , ! yy
tire 7)
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW U ��"
LIABILITY INSURANCE POLICY ! OTHER TYPE INDEMNITY BOND I,_' VG'76 ='
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 J
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#!M10335 E SIGNATURE
MP Q MGF❑ JP 7 JGF 7 LPG!fl CORPORATION El# 2166 I PARTNERSHIP 0#1 ' LLC # A
COMPANY NAME:{Olsen Plumbing&Heating ADDRESS'P.O.Box 2026,357 Hokum Rock Road
CITY Dennis —1 STATE!! MA ZIP 02638 !TEL 508-385-5290
FAX1 508-385-6963 i CELL EMAILI
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