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HomeMy WebLinkAboutBLDG-19-004716 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • CITY YARMOUTH MA DATE February 20, 2C PERMIT# BLDG-19-004716 JOBSITE ADDRESS 5 CARRIAGE LN OWNER'S NAME SANDY SIDE CORP G OWNER ADDRESS P 0 BOX 525 YARMOUTH PORT MA 02675 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 1 BOOSTER CONVERSION BURNER COOK STOVE 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 El 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# 2166 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# 2166 PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS PO BOX 2026, CITY Dennis STATE MA ZIP 02638 TEL FAX CELL EMAIL Z_CO_S- 'd IGkrr' A'Ao� ,m -�� �u.,d �ro, %� -��V 1�-may ��� "z � r/ u�-'7-2/0'D"�'ti° ) �- - 47 1 2--07, 171 a-v✓ten' ' /// 3//-9? - -2/4f7A‘-firr% ?"' / /7 b-CIP V() 11-4/11 -),70 l //t/ o 11'%/ _;/,50 ,274.(-( -A” itiv to n fi)d S31ON M3In3J NV id #IIW2j3d $ :33d ❑ 0hI1Al2:3d 3H1 Sd S3A2J3S SIHI ON SaA S3J,ON NO1103dSNI 1VNId A1NO 3Sfl IO103dSNI 2IOd 39Vd SIHl S3ION NO1103dSNI SVS HOflOH ° .:t":- �»,€`.. ^` :'�<�-w. * .,'"�:' ."*�;�`;. - �� :�'����."'.r1=^,;'�� - - Vic, . �- .�.��- °s -=, >.+ Y ..a'+,�snnpfN». .�' �:.." _ x�'x"'x :!':"a'' -.:�• D'4"">.•• :.: „r,,,a.....:=,-:`.• fir','*,: r'• .. ck +�.• • • s,z-i"�",`Y"5< '„C u-,..-+.� fiX ,' gin: t`*- ": 4a"" �•,F,-- ,- `- "' ?:,<: ,cam.„ ,- _'., "4. * i=._ . ,-. ._ -r ` ' ,.�."K '.,Y: " a"�• wma„'iyF,_,..,' a, ",c•,;,. • -'•''• ' „" fir_ .,• . ; 'Jo, ,.',,wr .D As< _ ✓ l` . - ' i' �, „:,w ' ° R- i ? 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