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HomeMy WebLinkAboutBLDG-22-005114 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `7÷7777 6 CITY YARMOUTH MA DATE March 15.2022 PERMIT# BLDG 22 005114 ; : - JOBSITE ADDRESS 220 KATES PATH VILLAGE OWNER'S NAME KESSLER MILDRED C TR G OWNER ADDRESS M C KESSLER REVOCABLE TRUST 220 KATES PATH YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 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 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 • OTHER 1 OTHER DESCRIPTION:Gas Test 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 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❑ LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Murphv's Services,Inc ADDRESS. 34 White's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5087601660 FAX CELL EMAIL S310N M31A3a NVld #1IWN3d $ 333 El ❑ 1II1a3d 3H1 SV S3Aa3S NOI1V3IlddV SIH1 oN saA S310N NO1103dSNI 1VNId AINO 3Sf1 a0103dSNI 210d 30Vd SIH1 S31ON NO1103dSNI SVO HOflOa