Loading...
HomeMy WebLinkAboutBLDG-22-002946 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "^ = CITY YARMOUTH MA DATE INovember 19,2021 PERMIT BLDG-22-002946 JOBSITE ADDRESS 62 COLLINGWOOD DR OWNERS NAME CLANCY PAUL P G OWNER ADDRESS CLANCY PATRICIA A 62 MISCOE RD WORCESTER MA 01604 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW El 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 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 0 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©MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP ❑A LLC❑# COMPANY NAME. KEVIN LAMOUREUX PLUMBING&HEATIN ADDRESS. 61 Jobys Ln, CITY Osterville STATE MA ZIP 02655 TEL 5084202068 FAX CELL EMAIL S310N M91A321 NVld #IIW213d $ :22d ❑ 0 IIWH3d 3H1 SY S3A2i3S NOLLV011ddV SIHI oN saA S310N NO103dSNI 1VNld A1NO 3Sfl 2i0103dSNI 210d 39dd SIHl S3ION N01103dSNl SYJ HJl0H