HomeMy WebLinkAboutBLDG-17-005335 ti
5
,,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ram _
CITY YARMOUTH MA DATE y/�—/ 7 PERMIT# , IG' 17-cid5 55
JOBSITE ADDRESS / t-pro/J,� ROe OWNER'S NAME �r) 1-hot )(�i-�
OWNER ADDRESS TEL - FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL q i
PRINT
CLEARLY NEW: 17 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
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 ,
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 of o nowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pertinent pr. io •f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
r4 4111 if_
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX LICENSE# 15383 ' A URE
MP MGF JP - JGF LPG! CORPORATION # PARTNERSHIP # LLC .#
COMPANY NAME:LAMOUREUX PLUMBING 'ADDRESS 61 JOBYS LANE_ _ .
CITY OSTERVILLE STATE MA ZIP 02655 TEL'508-420-2068 „R
FAX 508-420-7992 CELL 508-292-5085 EMAIL Iamoureuxplumbing verizon.net
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
poi2 d L FEE: $ PERMIT# _.
X
PLAN REVIEW NOTES