BLDG-23-004598 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 'YARMOUTH MA•
• DATE (February 20,2023 PERMIT# BLDG 23 004598
JOBSITE ADDRESS 25 HAZELMOOR RD OWNER'S NAME TROTH GLORIA D
G OWNER ADDRESS 25 HAZLEMOOR RD SOUTH YARMOUTH MA 02664-2926 TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL
PRINT ❑ RESIDENTIAL El
CLEARLY NEW: El 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 1
DIRECT VENT HEATER
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 El NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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 LICENSE#
SIGNATURE
MP 0 MGF ❑ JP El JGF 0 LPG! 0 CORPORATION El#I I PARTNERSHIP ❑#I ILLC ❑#I I
COMPANY NAME: I I ADDRESS. I
CITY I I STATE I I ZIP I I TEL
I I
FAX I I CELL I I EMAIL I
I