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HomeMy WebLinkAboutBLDG-23-003307 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t I ; a CITY 'YARMOUTH I MA DATE (December 13,2024 PERMIT# BLDG-23-003307 JOBSITE ADDRESS 180 BAXTER AVE I OWNER'S NAME (SCHILTZ RICHARD H G OWNER ADDRESS ITVELIA-SCHILTZ JANICE 80 BAXTER AVE WEST YARMOUTH MA 02673 TYPEI TEL I OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO FIXTURES FLOORS—. BOILER BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER 1 DRYER FIREPLACE 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❑ 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. 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 I LICENSE# (Massachusetts I MP© MGF ❑ JP❑ JGF❑ LPGI CORPORATION❑# SIGNATURE COMPANY NAME: KEVIN LAMOUREUX PLUMBING PARTNERSHIP ❑#I lac #�� ADDRESS. 61 Jobys Lane, CITY Osterville STATE MA ZIP 026553518 TEL 5084202068 FAX CELL 5082925085 EMAIL