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HomeMy WebLinkAboutBLDG-22-006648 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k: CITY YARMOUTH MA DATE 'May 18,2022 I PERMIT# BLDG-22-006648 JOBSITE ADDRESS 52 ELLIS CIR OWNER'S NAME Gavle Williams G OWNER ADDRESS 52 ELLIS CIR YARMOUTH PORT MA 02675-1335 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: m 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOMISPACEHEATER 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# 10335 SIGNATURE MP©MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc❑# COMPANY NAME: RICHARD P OLSEN ADDRESS. PO BOX 2026, CITY 'DENNIS STATE [MA _J ZIP 026385026 TEL FAX CELL EMAIL oficeanolsenplumbinq.com S310N M3IA3d NVld #IIINH2d $ :33d ❑ 0 II1612:13d 3H1 SY S3A213S NOI1d31lddd SI1-11 oN saA S310N NO1103dSNI 1YNId A1N0 3Sf1 e10103dSNI 2JOd 3OVd SIHI S310N NOI103dSNI SVO HOflO J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 2:2 g CITY ` MA DATE" ,�L J PERMIT # JOBSITE ADDRESSLL_Yi-D1 e:.: 1::.5 � fL.i:.e OWNER'S NAME � ��l ,_,�.I�j► ( OWNER ADDRESS T . TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ' i RESIDENTIAL Ci( PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESII NO APPLIANCES Z FLOORS—+ BSM 1 I 2 3 4 5 6 7 8 9 10 11 12 13 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYERr=- FIREPLACE FRYOLATOR 1 FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN w' POOL HEATER 11 E £ E f ROOM / SPACE HEATER ROOF TOP UNIT + TEST — .y , UNIT HEATER �. - — :. -. UNVENTED ROOM HEATER 3U I LDING-D*PAR 1 Nr ' WATER HEATER OTHER lik).(1_4(AS WIC INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 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 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 ,y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi • all P inn of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Olsen ' LICENSE # M10335 SIGNATURE MP / MGF JP JGF LPGI CORPORATION ,# 2166 PARTNERSHIP # LC # COMPANY NAME:, Olsen Plumbing & Heating ADDRESS P.O. Box 2026, 357 Hokum Rock Road CITY Dernis STATE MA 'ZIP" 02638 TEL 508-385-5290 FAX 508-385-6963 CELL EMAIL i C_ L J E K ?),U NC-1 . Co rn