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HomeMy WebLinkAboutBLDG-23-000372 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK BLDG-23-000372 CITY YARMOUTH MA DATE July 22,2022 PERMIT# JOBSITE ADDRESS 845 ROUTE 28 OWNER'S NAME G OWNER ADDRESS TEL ] TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: El RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El 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 1 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY CI 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 El LPGI El CORPORATION❑# PARTNERSHIP ❑# LLC ❑# ] COMPANY NAME: Murphy's Services,Inc ADDRESS. 34 White's Path, ] CITY South Yarmouth STATE MA ZIP 02664 TEL 5087601660 1 FAX CELL EMAIL ] S310N M3IA32i N\ld #1I1A1213d $.33d 1111213d 3H1 SV S3A213S NOI1V31lddV SIHl ON sei S310N NO1103dSNI IVNId ATNO 3Sf1 2:10103dSNI d0d 30Vd SIHI S310N N01103dSNI SVO HOfOa