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HomeMy WebLinkAboutBLDG-17-005280 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ga14 BLDG 17 005280 k, _ CITY YARMOUTH MA DATE April 14, 2017 PERMIT# JOBSITE ADDRESS 9 UPTON RD OWNER'S NAME ATWOOD DAVID A G OWNER ADDRESS ATWOOD NORMA J 9 UPTON RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES FLOORS —, 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 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 S31ON M3IA H NV1d #LI VJ d $ :33d ❑ ❑1IW2:13d 3H1 SV S3n2:13S NOI1V3I1ddV SIHl oN seA S31ON NOI1.O3dSNI 1b'Nld A1NO 3Sfl 2lO±03dSNI HOd 3O`dd SIH1 S31ON NOILO3dSNI SVO HOflOH