HomeMy WebLinkAboutBLDG-18-003666 V
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
4 CITY YARMOUTH MA DATE /'a,-/9-/7 1 PERMIT# /' 96' /r CV eK
JOBSITE ADDRESS ! 1,/et...Cri 4 C/-) OWNER'S NAME
G !.lZi7flSA� lley Zola_ 1
OWNER ADDRESS TEL! S6o-aia- j i a FAX I 1
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL
PRINT 1 RESIDENTIAL u''
CLEARLY NEW:-- " RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-' BSM 1 ' 2 3 4 5 6 7 8 9—' 10 11 2 . 13 ' 14
BOILER .r— '--I r 1 I` .
L
BOOSTER --II "� i
CONVERSION BURNER -T
COOK STOVE 3
DIRECT VENT HEATER / li it ii
DRYER I
FIREPLACE Y „ ,
FRYOLATOR - I
FURNACE
GENERATOR _ I L
GRILLE i, --ifI ,
INFRARED HEATER _L
LABORATORY COCKS I 1 I
MAKEUP AIR UNIT ��
OVEN i — —1,t
POOL HEATER 1 I
ROOM 1 SPACE HEATER I Tr vIL
ROOF TOP UNIT IF (I t__ '1
TEST
UNIT HEATER
UNVENTED ROOM HEATER -l; `
a 4,
WATER HEATER — r-J[ r�
OTHER r _
i�
I I —_ I L I
INSURANCE COVERAGE
1 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 'Li
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 my . ledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian 'h all Pertinent provis. o he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX I LICENSE#.15383 SIGN.� � it
j�
f-1 -� I—I 1 PARTNERSHIP I I#1 1 tic 1#I I
MP MGF,_, JP ; JGF, , LPG! CORPORATION #
COMPANY NAME:VIN LAMOUREUX PLUMBING _I ADDRESS'61 JOBYS LANE
CITY OSTERVILLE STATE MA ZIP 02655 TEL 508-420-2068
FAX 508-420-7992 CELL 508-292-5085 EMAIL lamoureuxpiumbing@verizon.net