HomeMy WebLinkAboutBLDG-19-004504 SO#135745 $50
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�" �r._.. . �. MA DATE .1� « -9 PERMIT#/ i9 -d D YOf
�1�� CITY YARMOUTH 1/21/1
JOBSITE ADDRESS 1 MID
IRON DRIVE OWNER'S NAME THOMAS WHITE
HITE
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.... 297 1537 IFAX
OWNER ADDRESS SAME TEL 401
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ViPRINT
CLEARLY ____ ___
NEW: „ RENOVATION: REPLACEMENT: v 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 i i
DIRECT VENT HEATER =' t
DRYER
FIREPLACE ® ,
FRYOLATOR _1 ,..
FURNACE
GENERATOR
GRILLE
1
INFRARED HEATER i
I�
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
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POOL HEATER i I
ROOM/SPACE HEATER I
ir I
ROOF TOP UNIT
I J I
TEST 4:
5 i I ( ,
UNIT HEATER i
UNVENTED ROOM HEATER '
, ,
WATER HEATER i
OTHER g
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES j / NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i 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.
CHECK ONE ONLY: OWNER -D AGENT "_
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application ar- 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 . pli. ce 1 h all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i i)
PLUMBER-GASFITTER NAME Richard J.Whiteside I LICENSE# 15850 W SIGNATURE
MP-_,„„; MGF _"4 JP JGF LPG!itjj CORPORATION / # 3969 PARTNERSHIP, #i J LLC J#;
COMPANY NAME: Murphy Services Inc ADDRESS 34 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-760-1660
FAX 508 760 1670 'CELLS (EMAIL cshea@calimurphys.com // klaube@callmurphys.com
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES