HomeMy WebLinkAboutBldg-20-000074 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
it+_ ; CITY YARMOUTH I MA DATE A-a..k--J 9 ' PERMIT#/, /O6—ge,`C O 7f
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JOBSITE ADDRESS 9 m�-.'a1!1 rde OWNER'S NAME J��
GOWNER ADDRESS _1 TELz2,p3—Z)3 -g73, FAX l
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL I
PRINT
CLEARLY NEW:Lie RENOVATION:0 REPLACEMENT: L PLANS SUBMITTED: YES ID NO
APPLIANCES Z FLOORS-, BSM 1 2 3 4 5 ppppl. 6 7 8 9 10 11 12 13 14
BOILERII. I
BOOSTER I
RR.1, ,
CONVERSION BURNER
COOK STOVE I `I s
DIRECT VENT HEATER
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DRYER i
FIREPLACE I _ ,
FRYOLATOR i 3
FURNACE I , I l 1 ' .... 1 1
GENERATOR
GRILLE = .
INFRARED HEATER d
LABORATORY COCKS
MAKEUP AIR UNIT ! Is 1
OVEN I l I I 1 '1 � ;1
ROOMPOOL HEATER ppoplip '
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TEST n 1 III
v_r t UNVENTED ..
UNIT HEATER I S
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WATER HEATER 1
OTHER a , , ,
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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 IE NO Q
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I] OTHER TYPE INDEMNITY El BOND 1 I
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 applicationwaives this requirement.
CHECK ONE ONLY: OWNER ® 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 the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia ---with all Pertin:iiiiir ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
4 ,i /. i i__ - An
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX I LICENSE# 15383 �T ATU'E
MP 13 MGF ED JP 0 JGF 0 LPGI Lj CORPORATION 0# PARTNERSHIP El# 1LLC 0#
COMPANY NAME:KEVIN LAMOUREUX PLUMBING&HEATING ADDRESS 61 JOBYS LANE
CITY OSTERVILLE I STATE MA ZIP 02655 TEL 508-420-2068
FAX 508-420-7992 I CELL 508-292-5085 EMAIL lamoureuxplumbing@verizon.net
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ //9
FEE: $ PERMIT# ��
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