HomeMy WebLinkAboutBLDG-19-002746 J13113 $50.00
` - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
=Vag CITY YARMOUTH MA DATE 10/29/18 PERMIT#71Y'%T , A.4
JOBSITE ADDRESS 23 BANISTER LANE URTN._
OWNER'S NAME COLLEEN CO . Y_,
EY E
OWNER ADDRESS 30 CLIFF RD MELROSE MA 02176 TEL 781-307 2751 FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT -
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO1 `.
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
:..�. �...:.0 .. I
COOK STOVE .
DIRECT VENT HEATER , _
DRYER ;
FIREPLACE
FRYOLATOR
FURNACE , i r a _. i ,
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
ems .
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
}
UNVENTED ROOM HEATER
WATER HEATER : 1
OTHER —_
t
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.
CHEC 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 r t ue an accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i lianc inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE# 15850 SIGNA RE
MP „_. MGF JP JGF LPGI CORPORATION=71#r3969 PARTNERSHIP'S#1 LLC #'
COMPANY NAME:Murphy Services Inc 1 ADDRESS 34 Whites Path t
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-760-1660
FAX 508 760 1670 CELL EMAIL cshea@callmurphys.com I/ klaube@callmurphys.com
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