HomeMy WebLinkAboutBLDG-16-001534 cab ) B -f
tMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
VrAfir CITY YARMOUTH , , MA DATE, _.. PERMIT# 136Dfrn' 00 ince"
JOBSITEADDRESS ,,,, /�c/g-EfaDA/_, I77C,,,..,..,'OWNER'SNAME !_?5,01,'s-yt'd., .
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OWNERADDRESS , . .....,..,_...,.........-....,........�.. :... w...„...... �_.._.... _,,..?TEL',.-.�,. .........,.., .. .. FAX .. ... .
TYPE OR .OCCUPANCY TYPE COMMERCIAL'-„i EDUCATIONAL : RESIDENTIAL',V
PRINT /
CLEARLY NEW:,1/4 RENOVATION:i.. REPLACEMENT:!,.,; PLANS SUBMITTED: YES.,'; NO
APPLIANCES 1 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 _
ROOMISPACE HEATER •'
ROOF TOP UNIT _
TEST ' 6-1:-..... .”
UNIT HEATER �
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UNV�Tkp cat Fi�EIE D
W aT I �-__
o HE2 SEP 16 2015
BU ILDINCytSj3TMENT ,
sr_ (//�L'j1 INSURANCE COVERAGE •
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 +.;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 I '
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 K ONE ONLY: OWNER ',,,,j 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 true and accurate to the best o y nowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliant- with all Pertinent p t Isis of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r
. « ..._._........ ........ ....: ._ I i ✓� - ,
PLUMBER-GASFITTER NAME iKEVIN LAMOUREUX LICENSE# 15383 •+el.,T R t
MP .+ ' MGF , # JP „,,,; JGF;,. ; LPGI',, ,? CORPORATION(,_:# PARTNERSHIP' ,,.#„ , ' LLC „ #
COMPANY NAME: KEVIN LAMOUREUX PLUMBING ADDRESS
61 JOBY'S LANE
CITY OSTERVILLE ' STATEMAZIP,02655 ; TEL 50A20,2068
FAX'508 20,7992 CELL 508,292-5085 :EMAILIIamoureuxplumbing@verizon.net
2if
ROUGH GAS INSPECTION NOTESTHIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
#61/- 124 ,07`re.-46‘ V,/ir Yes No ,
THIS APPLICATION SERVES AS THE PERMIT ❑ 0 -- ;��/�/_ t�{1 '_ !///
FEE: $ PERMIT# 4E/SI- // /6 /a
PLAN REVIEW NOTES ,
I
-
ti
�,AS The Commonwealth of Massachusetts . .
Deparbnent oflndustrial Accidents
_ ! OJ�ice of Investigations
. -; �,=`; • 600 Washington Street
- Boston,MA 02111
__ ` www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):‘ 17 / mi p r1(e t u' PA) siA t j fIr :n7
Address: 6,/ A/c Lan ,' l
City/State/Zip: rv.`//P, M/4- a26 s. ."-- Phone#: cal 21:- 50 D- s '
Are you an employer?Check the appropriate box: Type of project(required):
1.(I am a employer with / 4. 0 I am a general contractor and I
a have hired the sub contractors 6. 0 New construction •
employees(MI and/or part-time). .
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working forme in any capacity. employees and have workers'
(No workers'comp.insurance comp.insurance.. 9. Building addition
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL
insurance required,]t c. 152, §1(4),and we have no 120 Roof repairs
employees. [No workers' . 13.11-Other 1,Y. M(t&4g
comp.insurance required.]
. 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ..
.Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have '
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and Job site
information.
Insurance Company Name: &,con yovn' i /)n cv/i S .
Policy#or Self-ins.Lie.#:4.35-70/3- oo g 3/.15"0 --0- /e/ Expiration Date• 121-/.9' i4
Job Site Address: ,21g T�s✓vS;OA LAP a City/State/Zip:(U.�/q p(/ / ///tEQ t.
bc673
Attach a copy of the workers' compensation policy declaration page(showing the policy nunfber and expiration date).:.,.•
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of r
Investigations of the DIA for insurance coverage verification. -
I do hereby certify under the pairs and _ ofp iii at the information provided above is true and correct
Signature: / ( [.,ZTG/i Date: 9•-75,--Fr. .
]'hone#: •
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one): -
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone It: 1•