HomeMy WebLinkAboutBLDG-19-003632 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I
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_;ti.=54 CITY e \I armor Po(t- MA DATE \Z.,I ll-(2b18 PERMIT# , /2G'-/p—d0 360A
JOBSITE ADDRESS¢ (52, Maxim"( Sh0(e ed. {OWNER'S NAME FX1CP4e-
GOWNER ADDRESS TEL TEL FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ' RESIDENTIALR/
PRINT — —
CLEARLY NEW: RENOVATION:I 1 REPLACEMENT:L j PLANS SUBMITTED: YESD NOc/
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APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I—I ----r, k 1.------ I --7
BOOSTER 1: ' !�- — V ,
CONVERSION BURNER III—II-7 7 ' i` I �; _I
COOK STOVE
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DIRECT VENT HEATER 1—�, I•, i ^'
DRYER i II` �' i'
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FIREPLACE I J^1 ;_ i -1 _j
FRYOLATOR t I!
FURNACE I - J '' 7 I.
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GENERATOR I;; i � i ____1` ;_
i GRILLE 1_ '�
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INFRARED HEATER C _ J_____,::-
LABORATORY
COCKS i , I_� --;-_-_____7;-,,_----_- ___„� _I- I` °—
MAKEUP AIR UNIT ; i
OVEN — �'i t -- ;--
POOL HEATER _ IMI 1! _: ;l II i iL_ r_______
ROOM/SPACE HEATER M 11.111—i..1; 1
E ROOF TOP UNIT ST ' �IIM� 7 '1® _T
Tv- UNIT HEATER , _ , - _ _
UNVENTED ROOM HEATER !' t 1 V___`
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WATER HEATER ; V
OTHER ! I; �f f .: t,
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1 is 1' [, II > i�
INSURANCE COVERAGE
I 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 E. OTHER TYPE 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.
CHECK ONE ONLY: OWNER `tE' AGENT Ej
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 a ccurate e bes nowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn " n "th ertin •n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 741
PLUMBER-GASFITTER NAME Richard Olsen i LICENSE#i M10335 I SIGNATURE
MP E MGF Q JP 0 JGF D LPGI D CORPORATION,#12166 I PARTNERSHIP ritti LLC 7#1
COMPANY NAME:I Olsen Plumbing&Heating s ADDRESS I P.O.Box 2026,357 Hokum Rock Road i
CITY I Dennis STATE' ZIP(02638 ETEL f 508-385-5290 r
MA
FAX 508-385-6963 CELL EMAIL!
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