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HomeMy WebLinkAboutBLDG-22-002070 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK BLDG 22 002070 k„,e CITY YARMOUTH MA DATE October 12,2021 PERMIT# JOBSITE ADDRESS 51_DRIFTWOOD LN OWNER'S NAME PRICE LOUISE E G OWNER ADDRESS 51 DRIFTWOOD LN SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ 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 1 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 1 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 Q 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❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Murphy Services,Inc. ADDRESS. 34 white's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5087601660 FAX CELL EMAIL S31ON M3IA32!NVId #LII 3d $ 33d 1IWH3d 3HI SV S3Ai13S NOIiVOIlddY SIN' oN SOA S310N NOI103dSNl IVNId AlNO 3Sfl 210103dSNI 21Od 30Vd SIH1 S31ON NO1103dSN1 SVJ HJflO