The URL can be used to link to this page

Home My WebLink AboutBLDG-17-000411 co MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORIL "t3= CITY YARMOUTH MA DATE '-a4.-,1 PERMIT#ti' `-17-000'/�l � JOBSITE ADDRESS j- 0 zr .1,.. .J /7 L' WINNER'S NAME l/ ,// / GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL (--------- PRINT CLEARLY NEW: ✓ RENOVATION: REPLACEMENT:. PLANS SUBMITTED: YES' NO t/ APPLIANCES-1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 ' 10 11 12 I 13 12 BOILER - �- ---- BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER i 1 J DRYER — I ' FIREPLACE I FRYOLATOR FURNACE GENERATOR GRILLE ------r------- j I INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT f OVEN POOL HEATER } ROOM/SPACE HEATER _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER _ 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m% 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 best of m .awled„e and that all plumbing work and installations performed under the permit issued for this application will be in compliance th all Pertinent prow-'.. .f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. tea. _ di I, i PLUMBER-GASFITTER NAME KEVIN LAMOUREUX LICENSE# 15383 SI .' RE MP i MGF JP i JGF" LPGI CORPORATION „ # PARTNERSHIP # LLC # COMPANY NAME: LAMOUREUX PUMBING ADDRESS 61 JOBY'S LANE CITY OSTERVILLE STATE MA ZIP 02655 TEL 508-420-2068 FAX 508-420-7992 ' CELL;508-292-5085 EMAIL lamoureuxplumbing a@verizon.net ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE: $ PERMIT# y71 //—/ PLAN REVIEW NOTES `i! '5. I I i l Stttc The Commonwealth oflllassachusetts . Department of Industrial Accidents 41 _ -- Office of Investigations _ "era= _ 600 Washington Street Y, a iikih, ' Boston,MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print Legibly Name(Business/Organimtion/Individual): _v ei /eLin p L,e.e oy fl v O ;'fice j 1�a--71`„C Address: 6,/ lit/c La n City/State/Zip: /a: rYi.`/lam /LC 4- i:)'&s 1 Phone#: �4 i'- G � 6 fir' Are you an employer?Check the appropriate box: Type of project(required): 1.aI am a employer with / 4. El I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. , 7. 0 Remodeling ship and have no employees These sub-contractors have B. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers'comp. insurance comp. insurance.$ required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their ln, _ 3.ID �atrt a homeowner doing all work right of exemption ��8 m or additions myself.[No workers' comp. pti per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 134 Other-2) ,i/• ,r't F' l laCe comp.insurance required.] _ *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. •, ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below iv the policy and Job site information. Insurance Company Name: , .,e rtceo1 Ala ,/ v.:/1 S Policy#or Self-ins.Lic.#:61.1`9 A_ co (f.3A4.`o LS- /t,/ Expiration Da- 1", � / " Job Site Address: /5— prciarci Lt7 F City/Staxe/Zip: 4$6, 73 Attach a copy of the workers'compensation policy declaration page(showing the policy num r and expire n date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a '� fine up to$1,500 00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thep a %,pe of perjury that the information provided above Is true and correct. 0111 Signature: �i yzt Date: 7-.4�'` --/6 Phone#: e a, Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 3.Plumbing Inspector 6.Other Contact Person: Phone#: