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HomeMy WebLinkAboutBLDG-22-000375 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1=1-k �l CITY YARMOUTH MA DATE July 21,2021 PERMIT# BLDG-22-000375 JOBSITE ADDRESS •99 WHARF LN OWNER'S NAME SCHICKLER RICHARD G OWNER ADDRESS SCHICKLER CYNTHIA E 14 BARLOW MOUNTAIN RD RIDGEFIELD CT 06877-2416 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 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/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 El 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# 2166 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG' 0 CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: olsen plumbing corperation inc ADDRESS. 357 Hokum Rock Road, CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX I J CELL EMAIL S310N M3IA3H NVId #1101H3d $ 33d 111N213d 3H1 SV S3A213S NOI1VOIlddV SI H1 oN saA S310N N01103dSNI 1VNId AINO 3Sf1 H0103dSNI HOd 3OVd SIH1 S310N NO1103dSNI SVO Enna!