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HomeMy WebLinkAboutBLDG-23-003600 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 03,2023 PERMIT# BLDG-23-003600 JOBSITE ADDRESS 88 SILVER LEAF LN OWNER'S NAME DOHERTY BARBARA TR G OWNER ADDRESS BARBARA DOHERTY FAMILY TRUST 88 SILVER LEAF LN WEST YARMOUTH MA TEL 02673 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 ❑ 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 Q MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: OLSEN PLUMBING&HEATING ADDRESS. 357 Hokum Rock Road, CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX CELL EMAIL OFFICEOLSENPLUMBING.COM ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES S S A C H U S E T T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . " lfar = CI 1 MA DATE[12 v; PERMIT # I Ctr rncAkh ' . ,�. • 242 ...,�.-. OWNER'S NAME �_. DEC--2 9 U BIT A DDRESSI �.hx�8..._ [ e• x4 j i LA .. ___ .-_ � DDRESS r 1TEL[ jFAXL_. _ II � BUILLDIPs _ BY _ANT ` OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: X PLANS SUBMITTED: YES NO! APPLIANCES -1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER \ i BOOSTER • CONVERSION BURNER COOK STOVE I DIRECT VENT HEATER l' ..._. � DRYER FRYOLATOR _ _. .,..._.� - - FIREPLACE __- �_ __ FURNACE GENERATOR GRILLE F - -_ INFRARED HEATER _ _ ._ LABORATORY COCKS MAKEUP AIR UNIT OVEN .._. _._. _- , ., POOL HEATER }- ___: ROOM / SPACE HEATER ROOF TOP UNIT _ T TEST - .. _ --y-y-- UNIT HEATER ._. . _ .. - ___ -.._..._�. .�.. UNVENTED ROOM HEATER _ WATER HEATER OTHER — INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I 7! NO 2] I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 E 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�l nowledge 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. 7 � � 4. PLUMBER-GASFITTER NAME ' Richard Olsen LICENSE #�M10335 L/ SIGNATURE MP i MGF JP JGF LPGI CORPORATION 71#Fiji— PARTNERSHIP; #E_ LLC # COMPANY NAME: Olsen Plumbing & Heating ADDRESS[P.O. Box 2026, 357 Hokum Rock Road CITY 1 Dennis STATE I MA 1 ZIP 02638 ITEL 508-385-5290 FAX 508-385-6963 1 CELL EMAIL C ---�...' C C C?-1 . ' ?LV rn6 i N( •Co 1