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HomeMy WebLinkAboutBLDG-21-006850 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '_ CITY IYARMOUTH MA DATE (April21,2021 (PERMIT# BLDG 21 006850 JOBSITE ADDRESS 28 CROWELL RD OWNER'S NAME 'COULTER MARTIN CO TRS ' G OWNER ADDRESS 'COULTER KATARZYNA 131 OLIVER RD WABAN MA 02468 I TEL I ' TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL El CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 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 1 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 El 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 LICENSE# MP IDMGF ❑ JP ElJGF 0 LPG' ElCORPORATION❑#I I SIGNATURE PARTNERSHIP ❑#I ILLC ❑#I ' COMPANY NAME: I I ADDRESS. I CITY I 'STATE I I ZIP I I ITEL I I FAX I I CELL I I EMAIL -fie_ MA DATE �MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . tYCITY YARMOUTH -l�-�?3 PERMIT# C-1� ., 5. 7�<; � __�_ _ ._.r__T..._ .w JOBSITE ADDRESS g �.��.t //� ,,qq 7 6 jJ // C d LC2C.1/ OWNER'S NAME Cczr/S Ala►' C7 G OWNER ADDRESS // TYPE OR TEL -7z1-,�2y2- v;a& FAX PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL +-''- CLEARLY NEW: V RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO '-" APPLIANCES 7 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 FIREPLACEr. FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER — — ROOF TOP UNIT TEST I o 'µ -- UNIT HEATER __ UNVENTED ROOM HEATER -- I J W HEATER OTHER ii BULDlr INSURANCE COVERAGE 1 - -` 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 j OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Ceaeral Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 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 •:st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli nce with all Pert•• srovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4 PLUMBER GASFITTER NAME KEVIN LAMOUREUX LICENSE# 15383 - �,~6t � - MP � MGF SIGNATURE E JP Li LPGI CORPORATION # PARTNERSHIP # - LLC # _..�'. COMPANY NAME:LAMOUREUX PLUMBING AND HEATING ADDRESS 61 JOBYS LANE CITY 'OSTERVILLE STATE MA ZIP 02655 TEL 508-420-2068 —------ FAX FAX 508-420-7992 CELL 508-292-5085 EMAIL LAMOUREUXPLUMBING@VERIZON.NET :V