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HomeMy WebLinkAboutBLDG-23-000676 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .(- CITY YARMOUTH ] MA DATE August 09,2022 PERMIT# BLDG-23-000676 If � JOBSITE ADDRESS 52 LOOKOUT RD —1 OWNER'S NAME WILLIAMS DAVID R G OWNER ADDRESS WILLIAMS GAYLE H 52 LOOKOU--RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 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 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. 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 and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Gereral Laws. PLUMBER-GASFITTER NAME Richard Olsen LICENSE# 10335 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [ICHARD P OLSEN ADDRESS. PO BOX 2026, CITY DENNIS STATE MA ZIP 026385026 TEL FAX ]CELL EMAIL office a(,,olsenplumbing.com S310N M31A32:1 NVld #lIV fld $ :33d IIWa3d 3Hl SV S3AH3S NOLLY011dd`d SIHl oN seA S310N NO►103dSNI TVN d /ONO 3Sl 210103dSNI 2i0d 3OVd SIHl S310N NO►103dSNI SVD HJf OH MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1r. n Ri her�e + V , . . Urrnol C) . � MA DATE��,$���� _ : PERMIT# Z3- bt7� _ AU 8 20Y4'BS E ADDRESS 5-2_ mocoUt_ roadOWNER'S NAME W,j j1 i(am s __ _ ._____ __ d ___ f ►:R ADDRESSr 'TELL IFAX p= t r°ARTMENT i w ____. ---02AACY TYPE COMMERCIAL EDUCATIONAL .� RESIDENTIAL] CLEARLY NEW: RENOVATION: REPLACEMENT:; PLANS SUBMITTED: YES'-- NO APPLIANCES 1 FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1, BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ._ .. ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER j INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I v,P NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 and accurate tot best "yowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance.wi all P in �'i ' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7 PLUMBER-GASFITTER NAME Richard Olsen LICENSE# M10335 SIGNATURE # .. MP MGF'; JP rm. JGF LPG' 7 CORPORATION 2166 PARTNERSHIP # LLC 1#L_ Olsen Plumbing&Heating ADDRESS P.O.Box 2026, 357 Hokum Rock Road COMPANY NAME .. — ..... CITY Dennis 1 STATE' MA ZIP 02638 TEL 508-385-5290 ! FAX 508-385-6963�CELL. EMAIL C;��: ,C. C CO Q L.J E 1?L*) . 1 NL •CO cf 1 1