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HomeMy WebLinkAboutBLDG-21-004279 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 30,2021 PERMIT# BLDG-21-004279 JOBSITE ADDRESS 39 PAYSON PATH OWNERS NAME JOHNSTON ALVIN 0 G OWNER ADDRESS JOHNSTON MARTHA LEE 39 PAYSON PATH WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY❑ BOND 0 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❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Murphy Services Inc ADDRESS. 34 White's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5087601660 FAX CELL EMAIL S310N M3IA321 NVId #iIIN213d $:333 ❑ ❑ .I1%13d 3H1 SV S3A?J3S NOIlVOIlddV SIH1 oN sGA S31ON NO1103dSNI IVNId ,LINO 3Sfl N0103dSNI aOd 30Vd SIHI S310N NO1103dSNI SVO H0f1021