HomeMy WebLinkAboutBLDG-19-002934 J13127 ''
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`:a`Lia,x CITY YARMOUTH MA DATE 11/7/18 PERMIT#�.i)e, ('U0.�7
JOBSITE ADDRESS 23 STILLBROOK RD OWNER'S NAME ANNA FILIPPOVA
GOWNER ADDRESS SAME TEL 508-221-4987 JFAXL
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL -1 RESIDENTIAL �I
PRINT
CLEARLY
Y
NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES' i NO,
APPLIANCES Z FLOORS-i BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER il
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
-
FURNACE '
GENERATOR
GRILLE
INFRARED HEATER i
LABORATORY COCKS .,, .... .__
MAKEUP AIR UNIT
OVEN
_
POOL HEATER
„
ROOM/SPACE HEATER h °, __
ROOF TOP UNIT
TEST � �._.
UNIT HEATER
UNVENTED ROOM HEATER '1
WATER HEATER__
OTHER �. ..
3
....
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I F
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES �• NO mmm.
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 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.
CH K 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 applicat111,
rue an.' accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will • plia :with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I JV ,r
. .. ... . .„„__ ri fr AI
PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE# 15850 Itp SIGNATURE
MP MGF JP JGF . LPG171 CORPORATIONS # 3969 ]PART —SHIP LLC m #
COMPANY NAME: Murphy Services Inc ADDRESS 34 Whites Path
CITY South Yarmouth I STATE MA I ZIP:02664 TEL 508-760-1660
FAX 508-760-1670 CELLI EMAIL,cshea@callmurphys.com ll klaube@callmurphys.com
L/
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