HomeMy WebLinkAboutBLDG-17-001369 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE 9/6/16 PERMIT# / = f
JOBSITE ADDRESS! 26 BALSAM WAY OWNER'S NAME RICH PIMENTAL
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 1. 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 I I
FURNACE _ — — 1 --
GENERATOR __... _-�
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER 1
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
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.
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 . - .ue an' accurate to t'e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be• ,ilia :wit, 1;-- - t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE# 15850 SIGN' URE
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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