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HomeMy WebLinkAboutBLDG-22-004148 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY [YARMOUTH MA DATE 'January 25,2022 I PERMIT# BLDG-22-004148 F,r JOBSITE ADDRESS 1377 NORTH DENNIS RD I OWNER'S NAME BLAKE MARK J G OWNER ADDRESS BLAKE CHRISTINE G 377 N DENNIS RD YARMOUTH PORT MA 02675-2139 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 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 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 LABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY 0 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 0 JP 0 JGF❑ LPG' ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME I I ADDRESS. 161 JOBYS LANE, CITY IOSTERVILLE STATE MA ZIP 02655 TEL ' I FAX CELL EMAIL 1 S310N M3IA3H NVld #1.U1/1b3d $ :33d El ❑ 111183d 3H1 SV S3Ab3S NOIIVOIlddV SIHI oN saA S310N NO1103dSNI 1YNld AlNO 3Sfl 210103dSNI 2iOd 3OVd SIH1 S31ON N01103dSNI SVO HOflO I