HomeMy WebLinkAboutBLDG-17-001966 12Z01 $5D
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
=" CITY YARMOUTH MA DATE 9/27/16 PERMIT# __-
JOBSITE ADDRESS 12 CANVASBACK LANE OWNER'S NAME DEREK MENANGAS
GOWNER ADDRESS SAME TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: ' PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-4 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
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
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TEST
UNIT['EATER _
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 woe::not have the insurance coveraae required by Chapter 14?of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK 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 applicati. tru- a d rate to the est of my knowlecge
and that all plumbing work and installations performed under the permit issued for this application will b: ,, plia• with all Pe nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. "�
PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE# 15850 SIGNATURE
MP MGF JP JGF LPG' CORPORATION # 3969 PARTNERSHIP # LLC #
COMPANY NAME: Murphy Services Inc ADDRESS 34 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-760-1660
FAX 508-760-1670 CELL EMAIL cshea@callmurphys.com // ekarukas@callmurphys.com
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