HomeMy WebLinkAboutBLDG-19-003520 J13152 $50
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH . MA DATE 12/5/18 PERMIT#/ LO1' / -7a 5-26
JOBSITE ADDRESS 42 BOXBERRY LANE OWNER'S NAME MARK HAYNES
GOWNER ADDRESS 4 HUMMELL LANE SOUTHWICK TEL 413-348-0886 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL _ RESIDENTIAL;
PRINT
CLEARLY
NEW: RENOVATION REPLACEMENT: - u 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 1 '1...,
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER ;
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER iā
WATER HEATER
OTHER " .
z
ti -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Lij NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J= 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 are tr 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 i prh ā¢ nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Richard J.Whiteside LICENSE# 15850 IGNANRE
MP .v MGF JP JGF LPGI__ICORPORATION i '# 3969 PARTNERSHIP _ # LLC #r
_s
COMPANY NAME: Murphy Services Inc _ ADDRESS 34 Whites Path
CITY South Yarmouth ' STATE. MA ZIP 02664 1TEL 508-760-1660
FAX 508 760 1670 CELL ]EMAIL cshea@callmurphys.com /1 klaube@callmurphys.com
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ā ā
FEE: $ PERMIT#
PLAN REVIEW NOTES