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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
i= CITY YARMOUTH PERMIT# l oe--� Ol0 MA DATE �d_ -/ ��
JOBSITE ADDRESS it/jrgyi_loweR grace, OWNER'S NAME rS4j-e / LQ e
G OWNER ADDRESS TEL /
��a-�3z-9167 FAX
TYPE OR OCCUPANCY TYPE COMMERCIALE' EDUCATIONAL RESIDENTIAL'!.
PRINT
CLEARLY NEW:[ RENOVATION: REPLACEMENT:Li PLANS SUBMITTED: YES NO14
APPLIANCES 7 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
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER j
ROOM/SPACE HEATER 'r
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
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 [1 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
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 b: fof my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli -ce with all Pertin: • ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX I LICENSE# 15383 SI NATURE
MP MGF( JP r- JGF LPGI CORPORATION Q# PARTNERSHIP # LLC D#� _J
COMPANY NAME: KEVIN LAMOUREUX PLUMBING&HEATING1 ADDRESS 61 JOBYS LANE 1
CITY OSTERVILLE STATE MA ZIP 02655 TEL 508-420-2068
FAX[508-420-7992 I CELL 508-292-5085 EMAIL lamoureuxplumbing@verizon.net
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