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HomeMy WebLinkAboutBLDG-22-003244 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 07,202'PERMIT# BLDG-22-003244 If fy" JOBSITE ADDRESS 101 DIANE AVE OWNER'S NAME SHEPARD RONALD P G OWNER ADDRESS SHEPARD ROSALYN A 160 ROOSEVELT AVE SPRINGFIELD MA 01118 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES El 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 El NO 0 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 Ikevin Lamoureux LICENSE# IMA SIGNATURE MP©MGF El JP 0 JGF El LPG' 0 CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IKEVIN LAMOUREUX PLUMBING&HEATIN I ADDRESS. 161 Jobvs Ln, CITY IOsterville I STATE MA ZIP 02655 TEL 15084202068 FAX 5084207992 CELL 5082925085 EMAIL I S310N MIAAA3IAal NVld #.IW2:13d $ :3gd 1I11H3d 3H1 SV S3/183S NOIlVOIlddV SI1-11 oN Sad S310N N01103dSNI 1VNId A1NO 3Sfl icuo3dsNi 2I0d 39dd SIH1 S310N N01103dSNI SV0 HJl02�