HomeMy WebLinkAboutBLDG-19-001317 5-1' % ^1`iul Arm
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Ill CITY YARMOUTH MA DATE ,c,�-B I.�(3 PERMIT# %L-00 `9/'?
JOBSITE ADDRESS cPY Da r/MeOr /[ )Ay IOWNER'S NAME l ?(Se/tlzlr-U AEC/OA S
GOWNER ADDRESS - TEL (,3(-4-7 ,-V1/}FA j
TYPE OR OCCUPANCY TYPE COMMERCIAL° EDUCATIONAL❑ RESIDENTIALO----
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO2-
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 1011 12 13 14
BOILER —I, -
BOOSTER
CONVERSION BURNER —11 I I I ,•
I Imo'
COOK STOVE
DIRECT VENT HEATER I / 1 I I�l —1 I '
DRYER ' u
' FIREPLACE
FRYOLATOR I I 'I I(- 'I ------' I I 'I r—
FURNACE .
GENERATOR — ;' — —
I
GRILLE • i i
INFRARED HEATER
LABORATORY COCKS 1 -. '
MAKEUP AIR UNIT
OVEN I—P I I I I-1, h I I I
-
POOL HEATER I I I I
ROOM I SPACE HEATER I it 11 I 0 1 I ;I I 1 I
ROOF TOP UNIT , I
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I 'I 1 I I 1--I
OTHER • 1 i
I
I I� illi
I I
II ''I III !.I 'y ii i II
INSURANCE COVERAGE
I 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 El OTHER TYPE 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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the b- .1 my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance 'th all Peri ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General taws.
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX LICENSE 15383 atC A1 JJRL��t�yG�
MP Q MGF❑ JP Q JGF❑ 1201❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# /
COMPANY NAME KEVIN LAMOUREUX PLUMBING& H ADDRESS 61 JOBY'S LANE
CITY OSTERVILLE STATE MA ZIP 02655 TEL 508-420-2068
FAX 508-420-7992 CELL 508-292-5085 EMAIL tamoureuxplumbing@verizon.net
ROUGH GAS INSPECTION NOTES THIS P,WE FOR INSPECTOR.ISE ONLY FINAL[VS ECTION NOTES
_ — Yes No
THIS APPLICATQ!{,SERVES ASTHE PER 0 0
— — FES: $ rLAN PERMIT ' _ `� T
I%EVIEW NOj _ 07C ,L5
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