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HomeMy WebLinkAboutBLDG-22-007237 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 14,2022 PERMIT# BLDG-22-007237 JOBSITE ADDRESS 3 JERUSHA LN OWNER'S NAME RUSSO JOHN M G OWNER ADDRESS 353 WASHINGTON ST WINCHESTER MA 01890 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY❑ BOND El 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# MA SIGNATURE MP El MGF❑JP 0 JGF 0 LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IKEVIN LAMOUREUX PLUMBING&HEATIN I ADDRESS. 61 Jobvs Ln, CITY Osterville STATE MA ZIP 02655 TEL 5084202068 FAX CELL EMAIL S310N AA31Aal NTId #IIW2i3d $ :333 ❑ ❑ lliVEd 3Hl SV S3ALI3S NOIlYOIlddd SIHL oN seA S310N NO1103dSNI 1VNI3 AlNO 39fl M.03cISNI 2JOd 39Vd SIHI S310N NO1103dSNI WO HDflO i