HomeMy WebLinkAboutG-13-142 - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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9. CITY YARMOUTH - a. PERMIT '
JOBSITEADDRESS(T Sdu-ezt_toa/ J OWNERS NAME Doi _Sy er-y1�c.....,,..- J
GOWNER ADDRESS LcQ°es'-t .„440.kt4.. �J TEL _ FFAX
TYPE
PRINTR OCCUPANCY TYPE COMMERCIAL I f EDUCATIONAL Li RESIDENTIALLt-C"
CLEARLY NEW:[ RENOVATION:i_t REPLACEMENT:D. PLANS SUBMITTED: YESD NO['
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 - 14
BOILER i �. M
BOOSTER
CONVERSION BURNER ° " ° r I G
COOK STOVE I'
11
DIRECT VENT HEATER ' / 1! i1 "�...
DRYER Y': 6 ZC1Z -+
FIREPLACE ' 74 . Z3
FRYOLATORr 'S \ir '_
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
l
POOL HEATER i
ROOM I SPACE HEATER t
ROOF TOP UNIT
TEST ?
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER — .__ ._
OTHER I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ILl NO j,,,�
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ej OTHER TYPE INDEMNITY Li BOND L_
OWNER'S INSURANCE WAIVER:lam 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 El AGENT L i
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 st of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compli e with all Perlin rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME j KEVIN LAMOUREUX LICENSE#'L.,--15383 SI NATURE
MP MMGF _J JP 0 JGF LJ LPGI Li CORPORATION[j#[ �� I PARTNERSHIP+L.,,,#,_m, -0.w,.. LLC. %#L____,J
COMPANY NAME:I-KEVIN LAMOUREUX PLUMBING ADDRESS[81 JOBYS LANE
CITY ;OSTERVILLE —j STATE^�MA�ZIP t 02655 JTEL[8-08-420-2068____ _ _(
FAX 508-420-7992 CELL 1508-292 5085 JEMAILL lamoureux�lumbing veri2on.net _ _- T _ mm ° - 1