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HomeMy WebLinkAboutBLDG-22-000415 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ----"="--k `"� s CITY YARMOUTH MA DATE July 22,2021 PERMIT# BLDG-22-000415 f tl JOBSITE ADDRESS 38 NORTH RD OWNER'S NAME MCINTYRE JUDITH A G OWNER ADDRESS 38 NORTH ROAD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL al 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El 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 0 MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: Murphy Services,Inc. ADDRESS. 34 White's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5087601660 FAX CELL EMAIL S310N M3IA32J NVId #1IV d $ 33d 11W213d 3H1 SV S3ALI3S NOI1V0IlddV SIHI oN saA S310N N01103dSNI 1VNIH AlN0 3Sfl aOlOadSNI HOd 30Vd SIHI S310N NOLL3 dSNI SVO HOf1021