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HomeMy WebLinkAboutBLDG-17-03953 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - kriell CITY YARMOUTH MA DATE February 03, 2C PERMIT# BLDG-17-003953 JOBSITE ADDRESS 156 OLD MAIN ST OWNER'S NAME WILSON BRUCE E G OWNER ADDRESS WILSON SHEILA A 156 OLD MAIN ST SOUTH YARMOUTH MA 02664 TEL "IN PE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESE NO© FIXTURES 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 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 • OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF 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. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Whiteside LICENSE# 3969 SIGNATURE MP❑ MGF❑ JP❑ JGFE LPGI❑ CORPORATION©# 3969 PARTNERSHIP ❑# LLC❑# COMPANY NAME: Murphy Services Inc ADDRESS 29 Maple Terrace, CITY South Dennis STATE MA ZIP 02660 TEL FAX CELL EMAIL 2/")/z(v -'2_7 . () 710 , /,/ _ _ S31ON M31A3H NV1d #_IM:13d $ 333 ❑ ❑11W2i3d 3H1 St/S3/\2I3S N011V011dd`d SIHI oN sei S31ON NO1133dSNI TdNld A1NO 3Sf1 HO1O3dSNI NOd 3O`dd SIH1 S3lON NOI103dSNI SVO HOfOei