HomeMy WebLinkAboutBLDG-17-000931 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY A. -QYtYlc?U V\ - I MA DATE; l7A 1! a. 1 PERMIT# db% 000 I
JOBSITE ADDRESS ICA, _Qtr tliJ:\_ OWNER'S NAME 1 f hg,_
GOWNER ADDRESS I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL �R EDUCATIONAL 'zoJ RESIDENTIAL gj
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CLEARLY NEW:' RENOVATION: REPLACEMENT:V.I PLANS SUBMITTED: YES NOIKil
APPLIANCES 7 FLOORS-* BSM 1 i, 4 1 5 6 7 8 9 10 11 12 13 14
BOILER
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BOOSTER
CONVERSION BURNER ..�
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COOK STOVE I a.a
DIRECT VENT HEATER
DRYER ",- I it
FIREPLACE :.
FRYOLATOR I - =i f,.
FURNACE ¢
GENERATOR
GRILLE ..
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INFRARED HEATER mE � f
LABORATORY COCKS '
MAKEUP AIR UNIT i
OVEN _ _.r_�,,,��,.�....�.�..,._:.. _ =
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POOL HEATER
ROOM/SPACE HEATER ` __,-„„4-,-___,,,,,
ROOF TOP UNIT '` -=., z' �. -
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TEST
UNIT HEATER 1
UNVENTED ROOM HEATER "�� i
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WATER HEATER
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 (' NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY v 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 ',.I. 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 a • - curate to tr- best of m owledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp!.- , th all P- ne • • . o f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME[Richard Olsen LICENSE# M10, : ,:/ BSI IN 1 IRE
MP i i p MGF IL. JP JGF LPGI CORPORATION` # 2166 PARTNERSHIP 4 LLC[ #
COMPANY NAME Olsen Plumbing&Heating ADDRESS I P 0 Box 2026,357 Hokum Rock Road
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CITY Dennis STATEMZIP02638 TEL'508 385 5290
FAX 508 385-6963 i CELLI 1EMAIL