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HomeMy WebLinkAboutBLDG-22-002060 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK »�. CITY YARMOUTH MA DATE 'October 12,2021 IPERMIT# BLDG-22-002060 JOBSITE ADDRESS 232 PLEASANT ST OWNER'S NAME SEELEY ANNE BARUS(LIFE EST) G OWNER ADDRESS 232 PLEASANT ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 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 ❑ 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 General Laws. PLUMBER-GASFITTER NAME 'Richard Olsen LICENSE E 110335 SIGNATURE MP©MGF 0 JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME 'Olsen Plumbing 8 Heating I ADDRESS. IPO BOX 2026, CITY 'Dennis STATE MA ZIP 02638 TEL 15083855290 FAX CELL I I EMAIL ' S310N M3IA32i NVId #111AN3d $ :333 El 1Ik IH d 3E11 SV S3AH3S NOI1VOIlddV SIHI oN saA S310N N01103dSNI 1VNld A1NO 3Sfl i IO103dSNI 30Vd SIH. S310N N01103dSNI SVO HJfIO'