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HomeMy WebLinkAboutBLDG-22-02732 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _ CITY YARMOUTH MA DATE November 11,202'.PERMIT# BLDG-22-002732 JOBSITE ADDRESS 5 MAYFLOWER RD OWNER'S NAME HEALY SHEILA C G OWNER ADDRESS 53 ELLINGTON RD QUINCY MA 02170 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 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 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 0 OTHER OF INDEMNITY El 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 at 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 I LICENSE# 15850 SIGNATURE MP❑MGF❑JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME Murphy Services,Inc. ADDRESS. 134 White's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 15087601660 FAX CELL I I EMAIL ' S31ON M3IA3LI NVld # LIt'N ld $ :93A ❑ El 11Wa3d 3H1 SV S3AH3S NOI1V lddd SIHI oN saA S310N NO1103dSNI 1VNId 11NO]Sfl I0103dSNI HOd 3JVd SIHI S310N N01103dSNI SVD HJf102i