HomeMy WebLinkAboutP-12-170 (20 Gooseneck Road) c � MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING4Z D
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*l.t-(_ City/Town:Yarmouth MA. Date: 9/30/11 Permit# 67-—441
Building Location:20 Gooseneck Road M#1351>#1 Owners Name: Rice
PType of Occupancy: Commercial ❑ Educational ❑ Industrial E Institutional ❑ Residential X.
New:❑ Alteration: ❑ Renovation: ❑ Replacement:® Plans Submitted: Yes ❑ No
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Check One Only Certificate
Installing Company Name: Hall Plumbing&Heating,Inc.
a Corporation C-2803
Address: 447 Old Chatham Road City/Town: South Dennis State: MA
El Partnership
Business Tel:508-385-9127 Fax:508-385-6604 ❑ Firm/Company
Name of Licensed Plumber:James Pazakis
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes gi No 0
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy if- Other type of Indemnity 0 Bond 0
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.
Check One Only
Owner 0 Agent 0
Signature of Owner or Owner's Aaent
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 • application will be In compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Gen- - . s.
By Type of License:
Title Plumber :Ignature , is ber
City/Town ❑ Master Llc- se Num•- ' -15030
APPROVED(OFFICE USE ONLY) Journeyman