HomeMy WebLinkAboutBLDG-17-002270 5V
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
.mil=l
"1•= ; CITY YARMOUTH MA DATE o -. PERMIT#' /& f7-CV079
JOBSITE ADDRESS 1 J/ 4,7AC L /Jt OWNER'S NAME
GOWNER ADDRESS TEL JFAX
TYPE OR OCCUPANCY TYPE COMMERCIALn EDUCATIONAL [J RESIDENTIAL it-
PRINT
CLEARLY NEW:[RENOVATION:Li REPLACEMENT:[' PLANS SUBMITTED: YES❑ NO[
APPLIANCES 1 FLOORS-• BSM 1 2 3 4 5 6 7 8- 9 10 11 12 13 14
BOILER 7 __,m '
BOOSTER
CONVERSION BURNER
COOK STOVE (-
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR ' I
GRILLE n
INFRARED HEATER Mi
LABORATORY COCKS ,
MAKEUP AIR UNIT
OVEN ' _ f
POOL HEATER '‘11!--1 a
ROOM/SPACE HEATER ROOF TOP UNIT � A
1 r-
TEST 1.111111111- 11111111 ME_ N11111111111UNVENTED UNIT HEATER
-•• - 1111111111
i..
WATER HEATER r
OTHER r-, r
Mil - •
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE 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.
CHECK ONE ONLY: OWNER AGENT ri
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 • y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pertinent • • .ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX I LICENSE#'15383 _ ' 1 t *Ae IRS?���
MP , MGF JP ' � JGF n LPG( CORPORATION
7 ❑# PARTNERSHIP❑# LLC❑#
'
COMPANY NAME: KEVIN LAMOUREUXPLUMBING I ADDRESS 61 JOBYS LANE I
x
CITY OSTERVILLE I STATE MA ZIP 02655 ITEL 508-420-2068 I
FAX(508-420-7992 I CELL508-292-5085 EMAIL tlamoureuxplumbing@verizon.net I
Lief
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES