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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-' � CITY WEST YARMOUTH MA DATE 5/25/18 PERMIT#/1I11"/e-0Q7�,
JOBSITE ADDRESS 22 JACKSON AVE OWNER'S NAME KEVIN O'BRIEN
G �Y
OWNER ADDRESS 125 ASHTEAD RD BRIDGEWATER, MA 02324 TEL 508-269-3308 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1 RESIDENTIAL
PRINT
CLEARLY „„"
NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z 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 I I'
FURNACE L
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT µ
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE 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.
CH'• ONE ONLY: OWNER AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applica on Ni e and.ccur. e to the b. o my knowledge
and that all plumbing work and installations performed under the permit issued for this application will ie in . .lianc- it all Pertin= provis.n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \l
PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE# 15850 SIGNATURE
MP MGF JP JGF LPG' CORPORATION # 3969 PARTNERSHIP Itti LLC =_
COMPANY NAME: Murphy Services Inc ADDRESS 34 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-760-1660 J
FAX 508-760-1670 CELL EMAIL cshea@callmurphys.com Il klaube@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 ❑ ❑
e&? 6Vr FEE: $ PERMIT#
PLAN REVIEW NOTES