HomeMy WebLinkAboutBLDG-16-005599 IL� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
- • C ITY i ` -1-ncLukcr, p 0 Y MA DATEI b 13 ai PERMIT#/J06,/d,00
JOBSITE ADDRESS Z4'2 -e (Q , . OWNER'S NAME P. W,}}_e___
GOWNER ADDRESS ,.— TEL FAX , ,
TPRINOIR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL _1 RESIDENTIAL
CLEARLY NEW: RENOVATION: , REPLACEMENT:LT,,-,,, PLANS SUBMITTED: YESTJ NO o E
APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6 7 I 8 9 10 11 12 g 13 14
BOILER , _. s
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BOOSTER I
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CONVERSION BURNER 5 i
COOK STOVE
DIRECT VENT HEATER _
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DRYER _,. ,_..,,�_. ,_e.-�- ,.. ,.
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FIREPLACE I 3
FRYOLATOR _ �...� .. �..�
FURNACE -�. I M.
GENERATOR P '
GRILLE ; ,1 x.
INFRARED HEATER °,
LABORATORY COCKS
MAKEUP AIR UNIT
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OVEN �..�
POOL HEATER �,.._. <'
ROOM I SPACE HEATER
ROOF TOP UNIT A_/s. :.
TEST i
UNIT HEATER ,.�..�_{sue_. .... ........�., ...:,..,.. ,�m,.�,w..:::
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f +'UNVENTED ROOM HEATER } 1
WATER HEATER m w I PF..__
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 I i NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 23 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: OWNE i AGENT
SIGNATURE OF OWNER OR AGENT /2
I hereby certify that all of the details and information I have submitted or entered regarding this application are tr ' acc to th t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i lance all Pe vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 2„e„
PLUMBER-GASFITTER NAME i Richard Olsen J LICENSE#g M 0335 1 SIGNATURE
MP MGF Li JP Y j JGFEI LPGI 0 CORPORATION %t# 2166 PARTNERSHIPD#; I LLC ##
Heating _ ._®. ___ Road T
COMPANY NAME: Olsen Plumbing& ,ADDRESS 1 P.O.Box 2026,357 Hokum Rock _ i.
CITY Dennis STATE I MA ZIP 02638 TEL 508-385-5290
FAX'L508-385 963 CELL 'EMAIL'
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