HomeMy WebLinkAboutBldg-20-002771 . , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
;Lvir CITY YARMOUTH w MA DATE If -7_,7 PERMIT# i6-40-cd277
JOBSITE ADDRESS `t 7 P,.,.,p ,a , ,d OWNER'S NAME May-icx L..ct-o0 d,0
GOWNER ADDRESS TEL g- j_ j-7 g-a76 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL L] EDUCATIONAL Ti - RESIDENTIAL[-
PRIENT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESLJ NOQ'
APPLIANCES 1 FLOORS-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER IIMM
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COOK STOVE _ III r_
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE GENERATORGRILLEINFRARED HEATER IIIIIIIIIIIIII
LABORATORY COCKS itiE,
MAKEUP AIR UNIT OVEN ininseera
a �al
NOUL HEATER
ROOM/SPACE HEATER1 WI
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
i IIII
I III
WATER HEATER 1
OTHER
111
r a _....
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO [l
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY FT OTHER TYPE INDEMNITY n BOND El
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 Q AGENT LJ
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:sot,y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance ith all.Pertinen on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX 1 LICENSE# 15383 S'-NATURE
MP Fl MGF JP F.] JGF I I LPGI n CORPORATION f# PARTNERSHIP n# LLC I]#
COMPANY NAME:KEVIN LAMOUREUX PLUMBING&HEATING ADDRESS 61 JOBYS LANE I
CITY OSTERVILLE , STATE MA (ZIP 02655 ITEL 508-420-2068 I
FAX 508-420-7992 1 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 ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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