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HomeMy WebLinkAboutBLDG-17-003544 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • 1.-jC ;70." IN F CITY YARMOUTH MA DATE 1/4/17 PERMIT# b--)7' t ✓5-yV JOBSITE ADDRESS 30 WILD HUNTER ROAD OWNER'S NAME BRIAN ROBBINS GOWNER ADDRESS SAME TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT 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 FIREPLACE FRYOLATOR FURNACE ' ' — GENERATOR I 1 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 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES i 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 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application a true d accur a to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be pli all P I t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE# 15850 SIGNATURE MP i MGF JP JGF LPGI CORPORATION i # 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 II ekarukas@callmurphys.com Lei'