HomeMy WebLinkAboutBLDG-20-002774 or-r�ram
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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"Eft_ CITY YARMOUTH MA DATE PERMIT#/))/--P -ao-00,777r
JOBSITE ADDRESS o2 443 r /1.(a;.y S./fetal OWNER'S NAME Kew A) ii4,, 4l6,,,,,,,a„.„,
GOWNER ADDRESS TEL 771 . 7a,„7_,4.7&. FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL a RESIDENTIAL
PRINT
CLEARLY NEW:[ RENOVATION: REPLACEMENT:n PLANS SUBMITTED: YES I_, NOD.'"
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER q I.
BOOSTER 11 u 11 11 1 J 1
CONVERSION BURNER
COOK STOVE I 1 1 1
1 .{U)
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1 . __!
DIRECT VENT HEATER / I 1J U l U U 11 1
DRYER
FIREPLACE 1011111J I 1 1
FRYOLATOR 1 11 (J U1 U 1 U 1
FURNACE
GENERATORI U 11
GRILLE ( U U Ili] JJ f
INFRARED HEATER 1 1 LABORATORY COCKS
MAKEUP AIR UNIT �f
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OVEN erg _
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT , 1 (i L 11 �(
TEST I II 11 ! 1
UNIT HEATER
UNVENTED ROOM HEATER .d ®� N
WATER HEATER I U U '
OTHER )
1 ME
1 ! II 11 11 U1 U i l U1 l -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ I OTHER TYPE INDEMNITY n BOND ri
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 Li
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 knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian ith all Pertinent p isi of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME KEVIN LAMOUREUX LICENSE# 15383 ` SIG AT RE
MP n MGF JP Li JGF- LPGI n CORPORATION(l# PARTNERSHIP❑# LLC Q#
COMPANY NAME:KEVIN LAMOUREUX PLUMBING&HEATING'ADDRESS 61 JOBYS LANE I
CITY OSTERVILLE I STATE MA ZIP 02655 ITEL 508-420-2068 I
FAX 508-420-7992 I CELL 508-292-5085 EMAIL lamoureuxplumbing@verizon.net I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT D El
FEE: $ PERMIT#
PLAN REVIEW NOTES r41(41—Ci Aa1. Off