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HomeMy WebLinkAboutBLDG-21-004282 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `' ` _` CITY YARMOUTH MA DATE January 30,2021 PERMIT# BLDG 21 004282 JOBSITE ADDRESS 14 WINCHESTER AVE OWNER'S NAME RIVARD GUY A G OWNER ADDRESS RIVARD LINDA A 27 SPUR LANE NEWINGTON CT 06111 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 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 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 © 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# 15850 SIGNATURE . MP© MGF ❑ JP 0 JGF❑ LPGI 12CORPORATION 0# PARTNERSHIP 0#— LLC ❑# COMPANY NAME: Murphy Services Inc ADDRESS. 34 White's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5087601660 FAX CELL EMAIL S310N M31A321 NVld #11WH3d $:33d ❑ ❑ 1111213d 3141 SV S3AN3S NOI1VOIlddV SIR! oN saA S310N NO1103dSNI IVNId NINO 3Sf1 N0103dSNI 21Od 3OVd SIHI S310N NO1103dSNI SVO HJfON