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HomeMy WebLinkAboutBLDG-22-02827 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 4 CITY YARMOUTH MA DATE November 16,202'PERMIT# BLDG-22-002827 !I JOBSITE ADDRESS 1151 OCEAN AVE I OWNER'S NAME PRIMPAS JOHN T G OWNER ADDRESS PRIMPAS PAMELA W 26 LAWTON LN FOXBORO MA 02035 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0 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 1 FRYOLATOR FURNACE GENERATOR GRILLE 1 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ BOND 0 OWNERS 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❑ JGF 0 LPG! 0 CORPORATION❑# PARTNERSHIP 0# LLC 0# i COMPANY NAME: Olsen plumbing corperation inc ADDRESS. 357 Hokum Rock Road, CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX CELL EMAIL S310N M31A3 NVld #lIL J d $ :933 ❑ ❑ 1111H3d 3H1 SV S3A2I3S NOIlb'OIlddV SIHl oN saA S31ON NO1103dSNI 1VNI3 AlNO 3Sfl el0103c1SNI ei0d 39dd SIHI S310N NO1103dSNI SVD HJl0H