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HomeMy WebLinkAboutBLDG-21-001803 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kBLDG' CITY YARMOUTH MA DATE October 06,2020 PERMIT# 21 001803 JOBSITE ADDRESS 426 WEIR RD OWNER'S NAME FORTI CHRISTINE A G OWNER ADDRESS 92 BROOKINGS ST MEDFORD MA 02155-5407 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO Erl 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 I 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 ❑ 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 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: KEVIN LAMOUREUX PLUMBING&HEATIN ADDRESS. 61 JOBY'S LANE, CITY IOSTERVILLE I STATE MA ZIP 102655 1 TEL 5084202068 FAX 1 (CELL I 1 EMAIL 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ` :? '. BLDG-21-002680 CITY YARMOUTH MA DATE November 10, 202( PERMIT # JOBSITE ADDRESS 426 WEIR RD OWNER'S NAME FORTI CHRISTINE A G OWNER ADDRESS 92 BROOKINGS ST MEDFORD MA 02155-5407 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ 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 — . 1 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 0 NO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. 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 0 MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # , _ PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: ADDRESS. 61 JOBYS LANE, CITY OSTERVILLE STATE MA ZIP 02655 TEL 5084202068 FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ R/G (Jlr-O FEE:$ PERMIT# o 0 PLAN REVIEW NOTES