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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
wti CITY YARMOUTH I MA DATE //-3 /4, PERMIT# 016 A.
JOBSITE ADDRESS I9 ei r'e iu %{c et d AID ril1 OWNER'S NAME M,ehule_l (741-ci-7
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ✓
PRINT
CLEARLY NEW: 'U' RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER F .0
BOOSTER 1 r
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER / l _i
DRYER l
FIREPLACE —U— J 1
FRYOLATOR
FURNACE
GENERATOR
GRILLE —'r
INFRARED HEATER
- y'
LABORATORY COCKS _
MAKEUP AIR UNIT
OVEN
POOL HEATER u_ if
ROOM/SPACE HEATER If —Ir- 1
ROOF TOP UNIT
TEST i► -4
UNIT HEATER
UNVENTED ROOM HEATER "
WATER HEATER �!
OTHER -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 I
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 best o • y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pertinent p : .n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME KEVIN LAMOUREUX 1 LICENSE# 15383 S : IATURE
MP - MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:KEVIN LAMOUREUXPLUMBING -"ADDRESS 61 JOBYS LANE
i
CITY [OSTERVILLE y F STATE MA ZIP 02655 TEL 508-420-2068
FAX 508-420-7992 1 CELL 508-292-5085 EMAIL lamoureuxpiumbing@verizon.net
Li?. It
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FIN}ALL INSPECTION NOTES
Yes No / OX
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ` `7L /7 /7/ 6
FEE: $ PERMIT#
PLAN REVIEW NOTES