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HomeMy WebLinkAboutBLDG-12-414 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK mi�ri= -roc p =�9= CITY I YARMOUTH �(J e j(— 1 MA DATE/o2m3/—// 1 PERMIT#6-12--1-114 JOBSITEADDRESSLSfrjf , a p lOWNER'SNAME y ,t t '-ai7 o NIVOWNERADDRESS St T—_ . —_...__ ___1TETEL-7 FAX7-- TYPE OR I PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIALL. i v � CLEARLY NEW:W✓ RENOVATION:LI REPLACEMENT:0 PLANS SUBMITTED: YES NO0 n APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 BOILER g_ BOOSTER r —`� 14 CONVERSION BURNER , C COOK STOVE riDIRECT VENT HEATERr �� ©52(3i�. 4... DRYER FIREPLACE FRYOLATOR �U LD1PtC C , j' FURNACE GENERATOR 02 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT — POOL HEATER ROOM/SPACE HEATER 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 (± 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 ;. -s BOND L 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 0 AGENT El 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 t.--best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ce with all P' •:nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. of ate( • {�y0 PLUMBER-GASFITTER NAME i KEVIN LAMOUREUX 3 LICENSE#I 15383 l SIGNATURE - MP'2J MGF J JPr t JGFU LPGIL CORPORATION ji#i 1PARTNERSHIP El#,, BLLC—:`## I COMPANY NAME:)KEVIN LAMOUREUX PLUMBING I ADDRESS 161 JOBYS LANE _ k-- CITY OSTERVILLE -- 1 STATE(M ZIP 02655 •�3TEL!508-420 2068 i FAX 508-420-7992 1 CELL!508-292-5085 :EMAIL!lamoureuxplumbin�aeverizon.net t