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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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if'-i CITY ;YARMOUTH ! MA DATE 1/0- ,-//�PERMIT#� L ' 2 S
JOBSITE ADDRESS/5$Sotu,%Se&Awnvc . .1 OWNER'S NAME I ,734-n_pA_Fr.js
G OWNER ADDRESS +TEL.$�8
ADDRESS [ csl4lN��" 3 ���,o �.pZo/oZFAXLs_.__
TYPE OR OCCUPANCY TYPE COMMERCIALU EDUCATIONAL Q RESIDENTIAL L
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CLEARLY NEW:[ RENOVATION:LI REPLACEMENT q.; _-i PLANS SUBMITTED: YESLi NO+,
APPLIANCES 1 FLOORS-, 9SM 1 2 3 4 5 6 7 8 9 ((p�1I = 14
BOILER
BOOSTER i! L. !ii I_ l ■� i
CONVERSION BURNERI •
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COOK STOVE I i Cl 8 21
DIRECT VENT HEATER /_p
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DRYER c
FIREPLACE ---
FRYOLATOR
FURNACE
GENERATOR
GRILLE �... -
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST- .,. .,
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER 7..__ _....
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E+,$NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY L9 BOND LI
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER .. . AGENT L 4
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the.est of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compli-• e with all Pe ,i(--r provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
..._..-..._..._..._,_._._.__.__.__.._.._.,..___..__----` " „, t_�_.� _
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX I LICENSE#1159-8-3- /iGNAT RE
MP'L MGF 0 JPL JGFr� LPGI$ CORPORATION#I—IPARTNERSHIP- t, AJ LLCM- #I- $
COMPANY NAME:[KEVIN LAMOUREUX PLUMBING -I ADDRESS X61 JOBYS LANE _W — _���� j
CITY IOSTERVILLE J STATEI�MA.1ZIP$02655 jTELi508-4202068 — i
FAX F5'08-420-79'9211 CELL!508-292-5085 IEMAILIIamoureuxplumbing@venzon.net 1