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HomeMy WebLinkAboutBLDG-22-006509 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH 1MA DATE May 11,2022 JPERMIT# BLDG-22-006509 JOBSITE ADDRESS 9 ORCHID LN OWNER'S NAME MCCORMICK LAWRENCE E G OWNER ADDRESS MCCORMICK MARY L 51 CROSS ST BELMONT MA 02178-3168 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 at 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 at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME KEVIN LAMOUREUX LICENSE# 15383 SIGNATURE MP El MGF 0 JP 0 JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. 61 JOBYS LANE, CITY OSTERVILLE STATE MA ZIP 02655 TEL FAX CELL EMAIL S310N MJIA NVld #IIV 3d $ :33d 7 Z 7/317 111%13d 3H1 SV S3A 3S NOI1VOIlddd SIW oN saA S3lON N01103dSNI IVNId AlN0 3Sfl Z10103dSNI 210d 39Vd GIRL S310N NOI103dSNI SVO HOfl0a