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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Argil CITY YARMOUTH MA DATE 4,1-/2-4' PERMIT# wf1 -19 copa
JOBSITEADDRESSn fror4Ufe Read IOWNER'S NAME 5,.y4r Lyon S 1
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G OWNER ADDRESS TE1.74,2S-70727 IFAx
TYPE OR OCCUPANCY TYPECOMMERCIAL EDUCATIONAL RESIDENTIALIII---
PRINT ❑ ❑
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ID NOEr
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER -Ir Ir 1, iJ f I 1 Ir rr liT it I ,
BOOSTER , I I I I I I
CONVERSION BURNER J
COOK STOVE I h I, I n i
DIRECT VENT HEATER J / 1 i
DRYER
FIREPLACE i1 II
FRYOLATOR
FURNACE i
GENERATOR
GRILLE I I I
INFRARED HEATER
LABORATORY COCKS o
MAKEUP AIR UNIT 1
OVEN
POOL HEATER • I ,1 ii h II
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
II 1
UNIT HEATER
UNVENTED ROOM HEATER _
WATER HEATER i t
OTHER I I I 1
I
—I1 d J n I 6 . i1 II I I
I I 1
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 D 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
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bes y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian ith all Pertinen ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME KEVIN LAMOUREUX LICENSE# 15383 S NATURE�rh1��/
MP Q MGF❑ JP Q JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME:KEVIN LAMOUREUX PLUMBING&HEATING ADDRESS 61 JOBY'S LANE
CITY OSTERVILLE I STATE MA ZIP 02655 TEL 508-420-2068
FAX 508-420-7992 CELL 508-292-5085 EMAIL lamoureuxplumbing@verizon.net
LiP /1-
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No 7/�
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THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FT4/14/(11 0
FEE: $ PERMIT# 77
PLAN REVIEW NOTES