HomeMy WebLinkAboutBLDG-18-003666 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1111 7 CITY YARMOUTH 1 MA DATE( 7_ p_/7 PERMIT# CjtP Od 11
JOBSITE ADDRESS J" 'p n_e U t") OWNER'S NAME �1�4-� F/or,'o
GOWNER ADDRESS J TEL s-?. - /7-e>,r 7 S FAX'
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL L—
PRINT
CLEARLY NEW: i✓' RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _-,� i_ _._
BOOSTER r-
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER ; / ,; ;,
DRYER J1i __l
FIREPLACE '
FRYOLATOR If,—
FURNACE
!
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN ! I.
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT li if
TEST
UNIT HEATER II -
UNVENTED ROOM HEATER r-
WATER HEATER '
y ,
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 the best of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pertinent pr i on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME KEVIN LAMOUREUX 3 LICENSE# 15383 SI NATURE
MP MGF JP - JGF LPG! CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:KEVIN LAMOUREUX PLUMBING&HEATING ADDRESS 61 JOBYS LANE
CITY `OSTERVILLE STATE MA ZIP.02655 JTEL,508-420-2068
FAX 508-420-7992 CELL 508-292-5085 EMAIL lamoureuxplumbing@venzon.net
V
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INS1,ECTOIt USE ONLY FINAL INSPECTION NQTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
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