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HomeMy WebLinkAboutBLDG-21-002889 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k, „ CITY YARMOUTH MA DATE November 19,202( PERMIT# BLDG-21-002889 JOBSITE ADDRESS 62 LUMBERJACK TRAIL OWNERS NAME SIMPSON EDWARD J JR G OWNER ADDRESS SIMPSON JANE L 62 LUMBERJACK TRAIL WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ED 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 1 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 I 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND 0 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 General Laws. PLUMBER-GASFITTER NAME richard olsen LICENSE# 2166 SIGNATURE MP© MGF 0 JP 0 JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: olsen plumbing corperation inc ADDRESS. 357 Hokum Rock Road, CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX CELL EMAIL S31ON M31A38 NVId #11M3d $:33d ❑ ❑ IJI41N3d 3H1 SV S3A213S NOI1VOIlddV SIHL oN saA S310N NO1103dSNI 1VNId AINO 3Sf1 80133dSNI MOd 39Vd SIR! S310N NO1133dSNI SVO HOflO