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HomeMy WebLinkAboutBLDG-23-001243 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �'� CITY YARMOUTH MA DATE September 07,202 PERMIT# BLDG-23-001243 FEs JOBSITE ADDRESS 67 TAFT RD OWNER'S NAME HAWKES GEOFFREY G TR G OWNER ADDRESS GEOFFREY G HAWKES LIVING TRUST 67 TAFT RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 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 LICENSE# 15383 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: ADDRESS. 61 JOBYS LANE, CITY OSTERVILLE STATE MA ZIP 02655 TEL 5084202063 FAX CELL EMAIL S310N M31A32U NVId #11W213d $:33d ❑ ❑ 111U3d 3H1 SV SAS NOI1V0IlddV SIH1 oN saA S310N N01103dSNI 1VNId AlN0 3Sfl a0103dSNI 2IOd 3OVd SIH1 S310N N01103dSNI SV0 HOf10N