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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
7 Mira
M VI , CITY SOUTH YARMOUTH ,MA DATE 6/29/18 PERMIT#/1,461,""/5
JOBSITE ADDRESS 14 MISTY LANE OWNER'S NAME STEVE PALMER 17531
GOWNER ADDRESS 30 AMY LANE HOLLISTON,MA 01746 TEL 508-596-5847 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:U PLANS SUBMITTED: YES ED NOD
APPLIANCES 1 FLOORS–. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _
BOOSTER SI ' ___ 'SS..
CONVERSION BURNER 11111111MMINIIIIMISIONINISMIONO011110111111101111111111111111111111
COOK STOVEa ss:_SSS # ._
DIRECT VENT HEATER
DRYER 1111011111111111.011111111111101100111010111101111101111101111111111111011111111111111111111
FIREPLACEss
FRYOLATOR
FURNACE110111111114/1014111111011111111Nallailligialillatin
GENERATOR
GRILLE 111111111.111111111111111111111111111111111111111131111011111011111101111111911111011111111111111101111111
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT - 5 fly S
OVEN 5 55555 5_555
POOL HEATER 11111111511111111111111111111111111111111111111111011111111111.111111ANINOIMINNUMIUNI
ROOM/SPACE HEATER
ROOF TOP UNIT linglIONNINI1131111—E
TEST
UNIT HEATER 555 5
UNVENTED ROOM HEATER 0.1111111111111111111.1I— IS
WATER HEATER
OTHER Sf _s11.11
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q 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 El
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 'NE 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 applic.••• . t - . r • - best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application wl •-Ri I r lI - - •rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
'r '
MLA `s
PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE#R0 y ✓ SIGNAT RE
MP❑+ MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑+ # 3969 miirRSHIP❑# LLC❑#
COMPANY NAME: Murphy Services Inc ADDRESS 34 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-760-1660
FAX 508-760-1670 CELL EMAIL cshea@callmurphys.com // klaube@callmurphys.com
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
(, THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /�/ };_�/�/ 6 J'
/f (S4 FEE: $ PERMIT# r'�0 /C Z--)e �� J
/ 0 V f�i(/l PLAN REVIEW NOTES _ I7/2�/-f/ "