HomeMy WebLinkAboutBLDG-19-002431 •
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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"L1=,f CITY YARMOUTH MA DATE 10/12/18 PERMIT# dr/9'-OO& ,�
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JOBSITE ADDRESS 53 POMPANO RD OWNER'S NAME MONIQUE CROWLEY
GOWNER ADDRESS SAME TEL 508-332-8618 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL D RESIDENTIALD
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CLEARLY NEW:D RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NOD
' APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOOSTER
CONVERSIONI j 1
COOK STOVE
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DRYER
FIREPLACE
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FURNACEFRYOLATOR
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GENERATOR
GRILLE I
LABORATORY COCKS
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POOL HEATER '
ROOF TOP II
TEST I JWATER HEATER 1 ,
UNIT HEATER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO D
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D+ OTHER TYPE INDEMNITY D , BOND D
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 D AGENT D
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application - - true an, acc - e to the best o '•y knowledge
and that all plumbing work and installations performed under the permit issued for this application will •-,;,,;. plia : •' all Pertinent provlsio of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ilobsa --
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PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE# 15850 SIGNATURE
MP Q MGF D JP a JGF D LPG'D CORPORATION Q# 3969 PARTNERSHIPD# LLC D#
COMPANY NAME: Murphy Services Inc ADDRESS 34 Whites Path •
CITY South Yarmouth ! STATE MA ZIP 02664 TEL 508-760-1660
FAX 508-760-1670 CELLI-1EMAIL csheaed callmurphys.com I/ klaubeed callmurphys.com
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
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FEE: $ PERMITc7!-e#
PLAN REVIEW NOTES // /V�/(i�//