HomeMy WebLinkAboutG-12-778 MASSAC USETTS UNIFORM APPLICATIG FO PERMIT TO DO GASFITTING
-\ Mau. Date 6 iZ 20].2, Permit CIZ- 77F
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�rit ,Owner's Name O\ARS1 I IAV I . TypeofOcatpancy RESIDENCE
i New o. Renovation ❑ Replacement Q Plans Submitted: Yes 0 No)2(
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SUB-BASEMENT _ ,
BASEMENT ,
FIRST(1ST)FLOOR )---
SECOND
SECOND(2ND)FLOOR
THIRD(3RD)FLOOR
a
FOURTH(4TH)FLOOR ,
FIFTH(5TH)FLOOR
SIXTH(6TH)FLOOR
SEVENTH(7TH)FLOORJJ
EIGHTH(8TH)FLOOR
A
Installing Company Name HALL OIL CO., INC.
Address 435 ROUTE 134 SOUTH DENNIS CheckCorporation
Certificate
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'�Courparsrioa 2338 C
Business Telephone 50$3983831 0 Partnership
Name of Licensed Plumber or Gasfitter WILLIAM H. POOLE JR 0 Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL
Ch. 142 Yes EC No O
If you have checked ma please indicate the type of coverage by checking the appropriate box.
A liability insurance policy )8( Other type of indemnity 0 Bond 0
GWINER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required
by Chapter 142 of the MGL.and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Owner 0 Agent ❑
I hereby certify that all of the details and information I have submitted(or entered)in above 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 provisions of the Massachusetts State
Gas Code and Chapter 142 of the General Laws. ,I d
By Type el ianse: eU lv poi—a-6
Title ❑ Plumber X Masts Signature of Licensed Pt unbertasfitter
City/Town ❑ Gasfiuer ❑ Journeyman License Number 12879
APPROVED(OFFICE USE ONLY)