HomeMy WebLinkAboutBLDG-18-004268 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`r 4IJ CITY 11Ck yonc �V 1 MA DATE tits 4.1 1 PERMIT# /O'^�-' -Od �'
JOBSITE ADDRESS 5 Q rOQS Ad, t,o , ,,r,I3 NNER'S NAME t_cunc, ilt;;.i;,yL{.c,•.-%,,ti►t.
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OWNER ADDRESS :� �t:.�ir�ctd ,4{v¢-� u�;;"�,a;}j,��,,r TEL�-$�-55 3 '�O 5$ FAX
TYPER OT OCCUPANCY TYPE COMMERCIALS J EDUCATIONAL ❑ RESIDENTIAL(
CLEARLY NEW: k RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO El
APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 'MII'M_I i ITT ____
BOOSTER MM - MGM
CONVERSION BURNER i J M M .0__ IM M.
COOK STOVE MMMIENIMIMMMIENEMMMIMMIIIIII
DIRECT VENT HEATER M _MMM'_: 11111Williii_
DRYER � = ��� ��
FIREPLACE
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FRYOLATOR L _i— -- '®L_� ___ r
GENERATOR �_ __
_ -- _1 r_�M
GRILLE __
INFRARED HEATER
i-1_Mi CM _ MI�MI
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U COCKS -7 _�M _— �M_M
MAKEUP AIR UN M - - —
__ M
OVEN �7
POOL HEATER MM „_ --_- M�� — -M _M
ROOM/SPACE HEATER !M � ��
_ �
ROOF TOP UNIT _, - -,- __ a
TEST ME — -- _ ___ 1 ` I M ME
UNIT HEATER I Th,! -- ' --1 --' ' _ _ __KINIMITI1M1
UNVENTED ROOM HEATER _ '_ i �� `——,,'
WATER HEATERra
—7- ,t----7 =� �
OTHER ' 01�.' _ MMEIMM
lNM I
I i` - Mirlial -1-- — i
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 ° OTHE.R 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 ❑ 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 e1 d a urat= he best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in'y., ph e wit all' inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //
PLUMBER-GASFITTER NAME Richard Olsen 'LICENSE#1 M10335 ° IGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION D# 2166 I PARTNERSHIP❑#I LLC❑#,
COMPANY NAME: Olsen Plumbing&Heating i ADDRESS P.O.Box 2026,357 Hokum Rock Road
CITY Dennis STATE MA 'ZIP'02638 TEL 508-385-5290
FAX 508-385-6963 1 CELL; EMAIL 1