HomeMy WebLinkAboutBLDG-17-002383 ". MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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‘Ih1_ CITY . \N , (tr.Inn 4 _ _ MA DATE: 1\/3 I I c I PERMIT##46-/7-oe 21S
JOBSITE ADDR SS'' 3 ei S 0 041 S l,,, ✓i v� 'OWNER'S NAME l ,cfh rI c.d( f
GOWNER ADDRESS 1 TELi 71s- 5790 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 7 RESIDENTIALZ.
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CLEARLY NEW:❑ RENOVATION:LJ REPLACEMENT: PLANS SUBMITTED: YESEI NO -1
APPLIANCES 1 FLOORS-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 7-7 ,- l 1_ t: 1:— J, i_ I k' -17
BOOSTER -- 'r---1i i ---17-7, j
CONVERSION BURNER ii_ =i I. -- 7---1._____ i
COOK STOVE �� I; ___. __ f= --
DIRECT VENT HEATER .J __.1-! J_ --
DRYER i; --
(REPLACE — ' � ' -1— — —���
—
FRYOLATOR I Ti_ ! I_
FURNACE i-�--��. —f-' — I--1- f,
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GENERATOR 1 !; i _
GRILLE I. i' _, i_ __ i
INFRARED HEATER cif I I I_
LABORATORY COCKS 1. i I I - 1 ___ice _ i
MAKEUP AIR UNIT - r----7 ,-i
-OVEN -- ! 1�— - - — --
POOL HEATER �-�
ROOM/SPACE HEATER __ 7-7
ROOF TOP UNIT
TEST ___I___ _i I' i _ _
UNIT HEATER —� ______'
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UNVENTED ROOM HEATER 1` 1 _T__
WATER HEATER ; : ; �
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OTHER i4 1 ;.
INSURANCE COVERAGE
!have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L'NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ' 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 J
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru acc to t nowledge
and that all plumbing work and installations performed under the permit issued for this application will be in nc h rti p of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME;Richard Olsen I LICENSE#1 M1 SIGNATURE
MP E MGF E JP JGF D LPG(E CORPORATION E#i 2166 z PARTNERSHIP 71#I LLC E#(
COMPANY NAME: Olsen Plumbing&Heating 1 ADDRESS 1,P.O.Box 2026,357 Hokum Rock Road
CITY f Dennis i STATE I MA ZIPS 02638TEL j 508 299
FAX 1508-385-6963 CELL EMAIL (p,v a n'S�h 1 l��mho n r o —� --
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201act- i' 6
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