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I \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY I YARMOUTH MA DATE ril___I- -,/ 1 PERMIT#CI tn-0'24 ei
JOBSITE ADDRESS I-l4,0,,,_,5"p triryttar.- -1 OWNER'S NAME
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GOWNER ADDRESS L_______Thet444,:x 1 TELny_rm. -42z4FAXl------;
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OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL U RESIDENTIAL Li?"
kt„., e,i PRINT:
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i,0 NEW::yr- RENOVATION: J REPLACEMENT:Ll PLANS SUBMITTED: YESJ NOD
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o1,- k••••PPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
in WOILER 1 I ir-57.-
l'. BOOSTER; : I
CONVERSION BURNER
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COOK STOVE
,▪ DIRECT VENT HEATER ,
• ) DRYER
1 W. FIREPLACE
FRYOLATOR
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FURNACE
GENERATOR
tC.:2, GRILLE / - i
INFRARED HEATER
V) LABORATORY COCKS - at
c.....1. MAKEUP AIR UNITF., : ,
--..._ OVEN
k POOL HEATER
. ROOM/SPACE HEATER
Vi...." TREOSOTF TOP UNIT
UNIT HEATER
UN VENTED ROOM HEATER '
WATER HEATER 11111111111INIMMINNININNININIIIININIIIIIIIIIIIIIIIIIIMMINIMINIII
OTHER
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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 IJ NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Lj OTHER TYPE INDEMNITY il 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 nj AGENT D
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 th est of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compli nce with all Pe t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. N
.4.4.2.4....t C41
PLUMBER-GASFITTER NAME[KEVIN LAMOUREUX 1 LICENSE#115383
I.................4 IGNATURE
MP 1+,1 MGF El JP 19:1 JGF 0 LPGI LI CORPORATION11#r—I PARTNERSHIP Ll# J LLC 0#I ;
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COMPANY NAME:FKEVIN LAMOUREUX PLUMBING J ADDRESSI 61 JOBYS LANE .
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CITY 1 O1-
STERVILLE STATE I- MA .IZIP[02655 /TEL]508420-2068 _I
FAX 508420-7992D CELLL508.292.5085 !EMAIL lamoureuxplumbingQverizon.net —L- ]
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