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HomeMy WebLinkAboutBLDG-22-001329 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' BLDG-22-001329 ,m„ CITY YARMOUTH MA DATE September 07,202 PERMIT# JOBSITE ADDRESS 19 CAPT DORE RD OWNER'S NAME BASSETT FORREST E G OWNER ADDRESS 19 CAPT DORE RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES ❑ NO 0 FIXTURES 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 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability,insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El BOND 0 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. 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'KEVIN LAMOUREUX LICENSE# 115383 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: 1 ADDRESS. 161 JOBYS LANE, CITY OSTERVILLE STATE MA ZIP 02655 TEL FAX CELL EMAIL 1 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 cp MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1:-=-7.14—=z-rl �'•'I f=g CITY YARMOUTH I MA DATE y'—/--,2 / PERMIT# tt_ JOBSITE ADDRESS / " _ , ® _, ', • 1 •4 OWNER'S NAME C;;Ar 1 QSSc G _TELI0 3g4^4Q 33 FAXJ ___J _ OWNER ADDRESS _ TYPE OR OCCUPANCY TYPE COMMERCIAL 11 EDUCATIONAL E RESIDENTIAL L PRINT CLEARLY NEW:[k RENOVATION:.J REPLACEMENT:I I PLANS SUBMITTED: YES Q NOILf- APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER if I I O I I BOOSTER CONVERSION BURNER 11 i 1! COOK STOVE 1 I 1[ I I .� ._- DIRECT VENT HEATER I i ill j I II. I I DRYER I I I II FIREPLACE / I I I I I I I I FRYOLATOR { I I 'I I FURNACE II L�, 4-1 ---+ I I GENERATOR I ( I � I I I _GRILLE I I I I !� I I I INFRARED HEATER J 1. l� v LABORATORY COCKS I $ T I , I __ _ _, _ MAKEUP AIR UNIT ,J _ .111 1 __ OVEN l ° i ,r11 I I POOL HEATER J J J J �J J ROOM/SPACE HEATER U �) al Ii ROOF TOP UNIT I d Jil d . I TEST J Ikl UNIT HEATER J J j j d U U I,I 1, U- , UNVENTED ROOM HEATER J I WATER HEATER I I I OTHERIi J 1 i f ,r 1 Jf i 1 II I IL il 1 IL I1 - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO I I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE INDEMNITY I I BOND [1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts GeneralLaws,-and that-my signature this permit--application waivesthis requirement. — CHECK ONE ONLY: OWNER fl AGENT Li SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bes • y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian = ith all Pertinent- ov.-ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME KEVIN LAMOUREUX [ LICENSE# 15383 - NATURE MP h MGF JP . JGF— LPGI I J CORPORATION(1# PARTNERSHIP I I# LLC I:1# COMPANY NAME:KEVIN LAMOUREUX PLUMBING&HEATINGI ADDRESS 61 JOBYS LANE 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 ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r