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HomeMy WebLinkAboutBLDG-23-003197 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w'= � CITY YARMOUTH MA DATE December 09,202; PERMIT# BLDG-23-003197 I l JOBSITE ADDRESS STATION AVE OWNER'S NAME TOWN OF YARMOUTH G OWNER ADDRESS 1146 ROUTE 28 SOUTH YARMOUTH MA 02664-4463 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL ❑ PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 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 1 OTHER DESCRIPTION:Gas Test 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 Whiteside LICENSE# 15850 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: IMurphy's Services,Inc ADDRESS. 134 White's Path, CITY 'South Yarmouth STATE MA ZIP 026641212 TEL I FAX CELL EMAIL I 67 �2�