HomeMy WebLinkAboutBLDG-16-004204 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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*Law CITY . m,� P . _ .._.....W _ MA DATE 1 ,_I. . Do_ PERMIT# /iI7%7 /G`Gd�o Oy
IJOBSITE ADDRESS qt .Lot°c if KrCI OWNER'S NAM
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GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL? EDUCATIONAL RESIDENTIAL'!,&
PRINT
CLEARLY NEW:__ '
RENOVATION: REPLACEMENT:Ej PLANS SUBMITTED: YES N0
APPLIANCES Z FLOORS—. BSM 1 2 3 4 5 6 7 1 8 9 10 11 12 13 1 14
BOILER _ t} ,.
BOOSTER I. 1, i
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CONVERSION BURNER
COOK STOVE a:
DIRECT VENT HEATER 4,� _ - �. yf
DRYER �n �°
FIREPLACE
FRYOIATOR ��
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FURNACE GENERATOR I ._m_ ._,_. _„ .I. . . _
GRILLE R �, .1,_.-. � 1. ... T.
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INFRARED HEATER
LABORATORY COCKS i
MAKEUP AIR UNIT s., .,� _, ,___.__ :� ,.. y t ., ..._e;I
.
OVEN I
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POOL HEATER I 1
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 9 UNIT HEATER r �� � �
UNVENTED ROOM HEATER _
WATER HEATER '2
OTHER '
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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 j v NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY BOND 1
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 v 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 ac urate t e best of'n y kpowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia- �fi h a ertin .Isi 'of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .-
PLUMBER-GASFITTER NAME Richard Olsen I LICENSE#F M1033 a SIGNAT E
MP MGF`.i JP, JGF LPGI CORPORATION 171#I 2166 PARTNERSHIP_3#1 1 LLC'. #
COMPANY NAME: Olsen Plumbin &Heatin "'
. 9 9 v ADDRESS�P.O.Box 2026,357 Hokum Rode Road
CITY Dennis
- i STATE MA ZIP�02638 �
P. �._: . TEL 508-385-5290
1FAX l 508-385-6963 J CELLI 1EMAILI
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Tom`- #