HomeMy WebLinkAboutBLDG-18-003081 I . - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
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��k1/ CITY �%AA )Y10%)is kQdYf_. ; MA DATE <<Iu(i1 PERMIT# /lh,v -47-'ao9611
JOBSITE ADDRESS ___S_Ci. fat CD 1A OWNER'S NAME P_ Van S {CYl6 _ ___.__e
GOWNER ADDRESS I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL EDUCATIONAL _
PRINT —_
CLEARLY ---
NEW. t- RENOVATION: REPLACEMENT:�_, PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ' '
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER = _ ___
DRYER
i.
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST r,
'_
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
.OTHER l_ .
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES i NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY BOND 1
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of th
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?
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur to best edge
and that all plumbing work and installations performed under the permit issued for this application will be in complia all P inent vi f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Richard Olsen LICENSE# M10 5 SIGNATURE
MP i MGF JP JGF LPGI CORPORATION i # 2166 PARTNERSHIP # LLC #
COMPANY NAME: Olsen Plumbing&Heating — ADDRESS P.O.Box 2026,357 Hokum Rock Road
CITY Dennis STATE MA ZIP 02638 TEL 508-385-5290
FAX 508-385-6963 CELL EMAIL'
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