HomeMy WebLinkAboutBLDG-17-005434 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY YARMOUTH _ MA DATE f.(_ /R- /7 PERMIT# -/6-17-- 51/341
JOBSITE ADDRESS ,21 tC- d OWNER'S NAME j<1 /--t ,f- - a
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL v
PRINT
CLEARLY NEW: i/ 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
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LL
INFRARED HEATER —"
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
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
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 an accurate to t b t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn Ii with all Pe ne provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX I LICENSE# 15383 IGNATURE
MP - MGF JP - JGF LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:LAMOUREUX PLUMBING •ADDRESS 61 JOBYS LANE
CITY OSTERVILLE STATE MA ZIP 02655 TEL 508-420-2068
FAX 508-420-7992 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