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HomeMy WebLinkAboutBLDG-22-005287 „.7:1, _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '_I CITY YARMOUTH kMA DATE March 22,2022 PERMIT# BLDG-22-005287 1 JOBSITE ADDRESS 1183 PINE ST I OWNER'S NAME SERPONE RICHARD L _, G OWNER ADDRESS 183 PINE ST YARMOUTH PORT MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12 PRINT CLEARLY NEW: © RENOVATION:❑ REPLACEMENT:❑ 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 LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY❑ BOND 0 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 hest of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with as Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME kevin Lamoureux LICENSE# IMA I SIGNATURE MP 0 MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: KEVIN LAMOUREUX PLUMBING 8 HEATIN ADDRESS. 61 Jobys Ln, CITY Osterville STATE MA ZIP 02655 TEL 5084202068 FAX CELL 5082925085 EMAIL S310N M3IA32i NVld #1IV I d $ :33d El El 1111213d 3H1 SV S3A213S NOI1V3IlddV SIH1 oN sa), S31ON N01103dSNI 1VNId AlNO 3Sfl 80103dSNI 210d 30Vd SIHI S310N NO1103dSNI St/J H0f10Zl