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HomeMy WebLinkAboutBLDG-22-006169 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'b MA DATE April 26,2022 PERMIT# BLDG-22-006169 CITY YARMOUTH 7� JOBSITE ADDRESS 48 MONOMOY RD OWNER'S NAME CHLUDENSKI MARK J G OWNER ADDRESS CHLUDENSKI LYNNE A 48 MONOMOY RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El 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 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 El 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 LICENSE# MA SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: KEVIN LAMOUREUX PLUMBING&HEATIN ADDRESS. 61 Jobvs Ln, CITY Osterville STATE MA ZIP 102655 TEL 5084202068 FAX CELL I EMAIL SALON M3IA321 NVId #llWa3d $:33d ❑ ❑ 1111$3d 3Hl SV SaA213S NOIlVOIIddV SIHL oN S9A S310N N01103dSNI 1VNId AINO 3Sfl N0103dSNI 2lOj 3OVd SIHl S3LON N01103dSNl SVO HOfON