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HomeMy WebLinkAboutBLDG-18-001249 St) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH I MA DATE g-- 3c (7 PERMIT#/ /g-001# l JOBSITE ADDRESS r e / , 1.I c) Rp c,J OWNER'S NAME ;ct o c A,.ei/lb 11 �. G F OWNER ADDRESS TEL �!7-�S�—�YSSJFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: (` RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES N0 APPLIANCES Z FLOORS-. BSM ` 1 2 3 4 5 6 7 8 ) 9 10 11 12 13 14 BOILER + - r --- r ---- � ,. BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER ii / DRYER FIREPLACE FRYOLATOR � . FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT - j` - : OVEN POOL HEATER _ ROOM/SPACE HEATER ROOF TOP UNIT I 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 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 t t of my knowledge and that all plumbing work and installations performed under to permit issued for this application will be in complia with l Pe nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �e �z st t0�zdIL�Q"�/Q PLUMBER-GASFITTER NAME KEVIN LAMOUREUX LICENSE# 15383 ' S GNATURE MP MGF JP JGF LPG! CORPORATION # PARTNERSHIP # LLC # —1 COMPANY NAME:KEVIN LAMOUREUX PLUMBING&HEATING i 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 1