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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
—F= CITY YARMOUTH MA DATE 7/28/16 PERMIT#.` Gc� 4
JOBSITE ADDRESS 3 TIMOTHY ROAD OWNER'S NAME RAFFY MOUSSA
GOWNER ADDRESS SAME TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW: RENOVATION: REPLACEMENT: / 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
DIRECT VENT HEATER
DRYER 1
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
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
L!ABIL!TY!NSLRANCE 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.
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 application tru and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will b c m I' nce it rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE# 15850 I ATURE
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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