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HomeMy WebLinkAboutBLDG-18-004950 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1`) 911; BLDG-18-004950 �— � CITY YARMOUTH MA DATE March 07, 2018 PERMIT# r JOBSITE ADDRESS 164 CAPT SMALL RD OWNER'S NAME GREENE BRENDAN L G OWNER ADDRESS 164 CAPT SMALL RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL ❑ PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 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❑ 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# 3969 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# 3969 PARTNERSHIP ❑# LLC❑# COMPANY NAME: Murphy Services Inc ADDRESS 29 Maple Terrace, CITY South Dennis STATE MA ZIP 02660 TEL FAX CELL EMAIL / C /71— S1ON MdIA H NV1d #iJV'J d $ :ddd 1=11101HAd AH1 SV SdAH S NOI±VOI1ddV SIHl oN seA SALON NOLLOddSNI 1VNId .IINO dSfl ddO132dSNI NOd 2JVd SIH1 SALON NOIlOdSNI SVJ HOflOH