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HomeMy WebLinkAboutBLDP&G-18-006912 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 5_ CITY U'�5 . kkax no 'IL MA DATE 10/c(' t 1 PERMIT#,/J?-67 "T J 4 JOBSITE ADDRESS I 1,S Cart cj\'‘,Y sex 1 L1C i OWNER'S NAME '(J , f 14ZQ t hbOn POWNER ADDRESS TEL J :FAX TYPE OR OCCUPANCY TYPE COMMERCIAL. EDUCATIONAL RESIDENTIAL E PRINT CLEARLY NEW: _ RENOVATION:l....i REPLACEMENT:X PLANS SUBMITTED: YES 7 NO A. FIXTURES Z FLOOR-i BSM 1 2 3 4 5 6 7 8 9 10 11 I 12 13 14 BATHTUB , al 1, ;3 CROSS CONNECTION DEVICE 4 f t DEDICATED SPECIAL WASTE SYSTEM j 1 I _ :I c DEDICATED GAS/OIUSAND SYSTEM I -+'I 'E DEDICATED GREASE SYSTEM ; DEDICATED GRAY WATER SYSTEM I (' ; J ;' U. R _-__ DEDICATED WATER RECYCLE SYSTEM ' ; i i DISHWASHER • 1 ; L DRINKING FOUNTAIN I I ( II I FOOD DISPOSER € v FLOOR/AREA DRAIN ] i i INTERCEPTOR(INTERIOR) 1 I' 1 KITCHEN SINK -I 1 i 1 4 LAVATORY 1 i 1, I ROOF DRAIN SHOWER STALL ! [ ;I SERVICE/MOP SINK I p' •°' i C� i TOILET URINAL ( 8 l_ • fir WASHING MACHINE CONNECTION 9 i , : WATER HEATER ALL TYPES ' 1 I I ; 1 t, WATER PIPING I ! !l i OTHER [ . I 11 I f 9 i� I�p I , E I 3 Ilt it INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 1.11 i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 7 BOND L_J 61643 W 9 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 Li AGENT I 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 €bes . y owledge and that all plumbing work and installations performed under the permit issued for this application will be in com 'ance Width al P ine ' s' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I RICHARD OLSEN 'LICENSE# M10 SIG ATURE MP E JP D. CORPORATION Witt 2166 !PARTNERSHIP❑#, I LLC®# COMPANY NAME OLSEN PLUMBING&HEATING <ADDRESS 1357 HOKUM ROCK ROAD CITY DENNIS (STATE i MA ? ZIP I02638 ! TEL I 508-385-5290 FAX 1508-385-6963 CELL l I EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ettt1 J CITY 15. lJ&rr n(10 I MA DATE. 6 is(I '6 PERMIT#, /AP-/?""��1/ JOBSITE ADDRESS, C'CLO % vQ vtc 1t. OWNER'S NAME !ej• bl 0 r\ G � Z�r OWNER ADDRESS TEl~ I FAX' i TYPE OR OCCUPANCY TYPE COMMERCIAL i ; EDUCATIONAL RESIDENTIAL 2 PRINT CLEARLY NEW:O RENOVATION:D REPLACEMENT: PLANS SUBMITTED: YES f NO1 APPLIANCES Z FLOORS 1 ©©Q Q 9 14 BOILER � iIIIiIIii I_______ 1 CONVERSION BURNER I !! !! ! ! DCT VENT HEATER t 7-11 FIREPLACE Ii {FRYOLATOR jl I FURNACE �, 7�n�GENERATOR ;; { ,i ' j1GRILLE G INFRARED HEATER ° 'LABORATORY COCKS � i I f I :j 1 MAKEUP AIR UNIT ! i' k— OVEN 1r—I ii ll r 1l—� POOL HEATER I ii ' I '' t ROOM/SPACE HEATER I ; I 1' • 11 I ROOF TOP UNIT 1 I I i { i T al [ TEST 1 i !` i' UNIT HEATER I I ' 11 d' 1 j, i I UNVENTED ROOM HEATER jp 17— °1 i WATER HEATER I i' , OTHER L I 1 / / • i g 1' i i it l I i p== 11 I i it ,'� t f i , t INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ��G 1 Gib LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY El BOND f 'J `i' / 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 E 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 a bes rfiy knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance •th al all �rfinen o of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '/ / / PLUMBER-GASFITTER NAME 1 Richard Olsen I LICENSE#!M10335 SIGNATURE MP 0 MGF 0 JP E JGF D LPG'❑ CORPORATION 0# 2166 PARTNERSHIP'S#j I LLC # COMPANY NAME: Olsen Plumbing&Heating I ADDRESS I P.O.Box 2026,357 Hokum Rock Road , CITY I Dennis j STATE; MA I ZIP;02638 ftEL 1508-385-5290 FAX I 508-385-6963 CELLI EMAILI -J L '_ 4