HomeMy WebLinkAboutBLDG-18-001662 ,3\-)--1-4T----\---- l '2 ‘/IL) ' \
Ir MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
t CITY West Yarmouth i MA DATE 09/21/2017 _PERMIT#/*-4b'-77-'DO/6��
JOBSITE ADDRESS 17 Burnaby Street OWNER'S NAME Gary Simeone
GOWNER ADDRESS P.O Box 442 West Brookfield,MA 01585 TEL 508-450-8643 - FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL - RESIDENTIAL ,-j
PRINT
CLEARLY NEW:I I RENOVATION:U REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO( j
APPLIANCES 1 FLOORS— BSM 1 2 3 4 j 5 6 7 8 9 10 11 12 13 14
BOILER ILJ i I _ k
BOOSTER ° _ j
CONVERSION BURNER I j I
COOK STOVE _ s 1
DIRECT VENT HEATER -1
DRYER I �r t- 1
FIREPLACE e it is I
FRYOLATOR '� .
FURNACE r 1 -- 1 _
® ,r—
GENERATOR I
GRILLE 1 .11-
INFRARED HEATER I_- 1I U I
LABORATORY COCKSAL L.1
MAKEUP AIR UNIT 7 'r -1
OVEN J 1
POOL HEATER 1 - _ ,; 1
ROOM/SPACE HEATER ` _ -
ROOF TOP UNIT L , V r
TEST [- i—
UNIT HEATER E. F II t
UNVENTED ROOM HEATER _
WATER HEATER C j -r_r—�
OTHER jr 1!-
1; i ., 1
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 Q 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 U AGENT jai
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicatio tru and ccurate to best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will b i pli with all in 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 0 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 3969 PARTNERSHIP❑# LLC❑#
COMPANY NAME: Murphy Services Inc ADDRESS 34 Whites Path
CITY ,South Yarmouth STATE, MA ZIPD664 TEL[508-760-1660
FAXE508-760-1670 CELL EMAIL cshea@callmurphys.com 1/ ekarukas@callmurphys.com
SEP 21, 2017 lekbe