HomeMy WebLinkAboutBLDG-20-005843 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
alit CITY YARMOUTH MA DATE May 14,2020 PERMIT# BLDG-20-005843
JOBSITE ADDRESS 10 CORDICK RD OWNER'S NAME SCOTT JOHN W
G OWNER ADDRESS SCOTT JULIE B PO BOX 511 READING MA 01867 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
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CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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
DIRECT VENT HEATER
DRYER
•
FIREPLACE 1
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'ith all 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❑ LPGI ❑ CORPORATION 0# 2166 PARTNERSHIP ❑# LLC ❑#I
COMPANY NAME: olsen plumbing corperation inc ADDRESS. Ipo box 2026,
CITY dennis STATE IW, I ZIP 102638 I TEL 5083855290
FAX CELL EMAIL
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