Loading...
HomeMy WebLinkAboutBLDG-22-004565 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I CITY 'YARMOUTH I MA DATE (February 16,2022 I PERMIT# BLDG-22-004565 JOBSITE ADDRESS 164 HOLLY LN I OWNER'S NAME MANNING DAVID J G OWNER ADDRESS MANNING MARY LOU 3 SHADY LANE WILBRAHAM MA 01095 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: © RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO El FIXTURES 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 1 DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El BOND 0 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. 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 knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME KEVIN LAMOUREUX LICENSE# 15383 SIGNATURE MP©MGF❑JP❑ JGF❑ LPG( ❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: ADDRESS. 61 JOBYS LANE, CITY OSTERVILLE STATE MA ZIP 02655 TEL FAX CELL EMAIL S310N M3IA321 NVld #JJ1/11b3d $ :33d ❑ ❑ 1I11213d 3H1 SV S3AH3S NOI1VOIlddb SIH1 oN s2A S31ON NO1103dSNI lYNI3 /LINO 3Sf1 H0103dSNI 803 3OVd SIHI S310N NO1103dSNI SVU HJf1021