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Home My WebLink AboutBLDG-15-005031 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �_1= CITY YARMOUTH MA DATE �/!D—/ - PERMIT# 6?) JOBSITE ADDRESS AE*/¢VS.e Rea01 _ OWNER'S NAME ��y 'Gb j U rr( ' GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: V- RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO 1/ APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNI ��JJ D UN1 EA ghgE�T WA-ER HEATERWO 911 OTF ER APR 13 2015 k3r t3UItDINC TMENT 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 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 b f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pertin vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME KEVIN LAMOUREUX LICENSE# 15383 IGNATURE MP f MGF JP JGF LPG! CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: KEVIN LAMOUREUX PLUMBING&HEATIffl'ADDRESS 61 JOBY'S LANE CITY OSTERVILLE STATE MA ZIP 02655 TEL 508-420-2068 FAX 508-420-7992 CELL 508-292-5085 EMAIL Iamoureuxplumbing@verizon.net de l! 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 SZtk The Comnwfivearlth of Massachusetts , Department of Industrial Accidents _ i# _ - Office of Investigations — _f 600 Washington Street �= --- Boston,MA 02111 ' www.ntassgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ,..rs n �i�wn fsc a &'.Y P y .. ru _ Address: 6,/ A),/ Lan City/State/Zip:f' er /lam. M D 6 sue~' Phone#: ._= ` C M-ego 6 2. Are you an employer?Check the appropriate box: Type of project(required): 1.(II am a employer with / 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp. insurance comp.insurance.: 10.0Electrical repairs required.] 5. ❑ We are a corporation and itsor additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.1kOther- b j/•. %,vre40t cu to 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 sows have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and site information. Insurance Company Name: 8 �7 r'r$c ovay f 1)?revi)S Policy#or Self-ins.Lic.#:4,.4.5 c �"70 A — c 3Nt O 0 f 1../ Expiration Date- _Qj'-/.9," 4411, Job Site Address: // A/40Se / Rr>q c' City/State/Zip:/i). /4-tr1604j ff4 D Atit7 3 Attach a copy of the workers'compensation policy declaration page(showing the policy ma i i r and expiration date). a , 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 a pains and / iiiiid ;• of perjury that the information provided above is true and correct. Signature: y /%IrG -kgaf,L,,ri_71) Date: ' ) Phone#: 3!-e g_ L f -O ._ o2pAk 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.C ity/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector . 6.Other Contact Person: Phone#: a .c ,—_� A 1 Cx\ _r