HomeMy WebLinkAboutBLDP&G-17-003307 • .\ MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMMBIN/G�WORK
riML1s CITY N . p%t OCA i MA DATE'- 11f f�l k PERMIT# A- / 7`c1i77
JOBSITE ADDRESS / L5'j h ,r �,/►.'��r p,,j.aOWNER'S NAME L.)a'bt'C •-Nt
pOWNER ADDRESS /A, SiCLI Ia w2 Or. \I av 046 LOA, TEL -�SSJ 4 calt,VAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:7 REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB r� I,
CROSS CONNECTION DEVICE a ,t_
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM _ __
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM !---- ` -- _.�v _ '_a
DEDICATED WATER RECYCLE SYSTEM _'IT I I
DISHWASHER
DRINKING FOUNTAIN _•t.
FOOD DISPOSER
FLOOR/AREA DRAT
INTERCEPTOR(INT I IOR) •
KITCHEN SINK ` -- -- -- - _ _� - , __
LAVATORY y'-
- s
ROOF DRAIN ,
SHOWER STALL I L11
SERVICE/MOP SINk'
TOILET -- —-- --
- _
URINAL A
i. I.•
WASHING MACHINE CONNECTION 3 •
•
WATER HEATER ALL TYPES _
WATER PIPING t -
OTEHOTEHR _.
--- ,
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 7 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.
CHECK ONE ONLY: OWNER ❑ 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 the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in eom liance witty I in n provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / t
PLUMBER'S NAME RICHARD OLSEN {LICENSE#1 M10335 I SIGNATURE
MPQ JP❑ CORPORATION❑M2166 'PARTNERSHIP❑#I ILLC❑#
COMPANY NAME OLSEN PLUMBING&HEATING I ADDRESS 357 HOKUM ROCK ROAD
CITY DENNIS STATE! MA I ZIP 102638 I TEL f 508-385-5290 4
FAX 1508-385-6963 I CELL I I EMAIL I
I
[7* ,,_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
=t1= CITY NI( v Ad .��4-� ' MA DATE; I1I s/f(,� PERMIT# 0��` �7—OG,
JOBSITE ADDRESS"ra cSJGj li b r,, Ai,\tt y-bu nr,i-I., :OWNER'S NAME , J e b Lc- Srz,-tee.
GOWNER ADDRESS /a sly,bne_ko I.U,' .Lictvwteci }in TEI Spg,;jiav--y j FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL;Ja EDUCATIONAL E RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:D REPLACEMENT; PLANS SUBMITTED: YESD NOD
APPLIANCES 1 FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I; f; .a i 1 _E l
-- — ;
BOOSTER ,, H f. • i sI
CONVERSION BURNER _ _'! i- -1__J, __I_ i II
COOK STOVE, '--- i '_
DIRECT VENT,HEATER ,- , i 7-1! __i �1� 3, i i
DRYER r J i —_.—�.
' I l i I i E i :� '-_�
FIREPLACE — — _ 1 — i .�_r; _�
FRYOLATOR > �` 1 i' � —_ - — ''�
E: _— ! r. __ _ i
FURNACE — c\1 i' f: .-- 7 l_ —�:
GENERATOR LU. cat Q •
7-7;
.—�•l; _ J� i -_,
GRILLE O w ; I ii I. �:_—� Imo_
INFRARED HE 015 Ii E'i' I` , ,_ _
LABORATOR" KS I' I `--i: Gam ' (^ • I
MAKEUP AIR --i' I; — 1— I
OVEN —, —, — -�-�
POOL HEATER '` I f. I�J °'' I
ROOM/SPACE HEATER ; is i i
—
ROOF TOP UNIT •_ 11• I _ 171 _
TEST I ;f I, I ! `.
UNIT HEATER -----,,— •
—'
I
UNVENTED ROOM HEATER J; _!
WATER HEATER L�i j __ _-1 _
' 1 __ , a__ ..
OTHER ; _I i; l, I, _J
_
I I. I
r
,
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [NO 7-7
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE iPPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LD OTHER TYPE INDEMNITY 1 BOND LI
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 AGENT E
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 compl�l with ap Perti t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / (/
PLUMBER-GASFITTER NAME Richard Olsen 'LICENSE#:M10335 GNATURE
MP Ej MGF❑ JP E JGF E LPGI D CORPORATION i.#12166 !PARTNERSHIP D# LLC 0#I
COMPANY NAME: Olsen Plumbing&Heating i ADDRESS P.O.Box 2026,357 Hokum Rock Road
CITY 1 Dennis I STATE; ;ZIP!02638 hTEL i 508-385-5290
r
FAX 508-385-6963 CELL EMAIL
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