HomeMy WebLinkAboutBLDG-19-000748 1 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
I9 CITY YARMOUTH MA DATE' 8-3/er PERMIT#/.PCT 4!—01d 791
JOBSITE ADDRESS (98 Oki (xurcA a 40WNER'S NAME 4 ';CA V2 m'K i
.G OWNER ADDRESS mg 774-330-flaw
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL❑--
PRINT
CLEARLY NEW:[V RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO[/j
APPLIANCES 1 FLOORS-. SSM , 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14-
BOILER r
BOOSTER I
CONVERSION BURNER I
COOK STOVE i
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE 1
INFRARED HEATER
LABORATORY COCKS lip r
MAKEUP AIR UNIT
OVEN
POOL HEATER I
ROOM/SPACE HEATER i
ROOF TOP UNIT I
TEST
UNIT HEATER yiUNVENTED ROOM HEATER I i
WATER HEATERme n _- i ,
OTHER
ii i i i i i
INSURANCE COVERAGE
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
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 pemrd application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and accurate to the best knowledge
and that all plumbing work and hsta1lations performed under the permit Sued fur this application will be in ' all Pertinent ' ' of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
ese
PLUMBER-GASFITTERNAME IKEVINLAMOUREUX IUCENSE# 15383 'a,c . TUURREcaztueca7 44
MP El MGF❑ JP 0 JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME KEVIN LAMOUREUX PLUMBINGBHEATING ADDRESS 61 JOBYS LANE
CITY OSTERVILLE STATE Q ZIP 02655 TEL 508-420-2068
FAX 508-420-7992 CELL 508-292-5085 EMAIL lamoureuxplumbing@verizon.net
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ROUGH GAS INSPWFION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVfS AS THE PERMIT [] ❑
-9.
FEE: $ PERMIT 0LL
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