HomeMy WebLinkAboutG-11-089 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
Alt yvvy u. .Mass. Date a-1 i 20 /o Permit', /,{r 0 8p
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t Bu{lding Location 02 f Sur irnea . Sr Owner's Name £ji--5 30 e if
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New • t on . Replacements;) PLsoc Submitted: Yes 0 N4ii
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SLB BASEMENT
BASEMENT
FIRST{1ST)FLOOR
SECOND(2ND)FLOOR t o J 9
n• ,' (3RD)FLOOR �/! �1� Q
Q "R •OURTH(4TH)FLOOR _ o. ) /A jeJ'"� we - tr
QY U' ;IFTH(5TH)FLOOR �. --""r .n <,.
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x •IXTH(6TH)FLOOR Cw 2 9
SEVENTH(7TH)FLOOR C
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. «a Comp. Name LL OIL CO., INC.
Address Check.one: Certificate 1
435 ROUTE 134 SOUTH DENNIS Corporation 2338 C
Business Telephone 508.398-3831 ❑ Partnership
Name of Licensed Plumber or Gasfitter WILLIAM H. POOLE JR 0 flnn Ca.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent s:-hich meets the requirements of MGL
Ch. 142 Yes No CI
If you have checked}_es,please indicate the type of coverage by checking the appropriate box.
A liability insurance policy DS:( Other type of indemnity CI Bond 0
OWNER'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 ❑ Agent In
I hereby certify that all of the details and information I have submitted(or entered)in above application are hue
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 Latins. tajeilamti A Pte-p
By Typeorlietnse:
Title ❑ Plumber X Master Signature of Licensed Pluntben'Gasf:ner
City/Town ❑ Gasfitter 0 Jomne}tra License Number 12879
1APPROVED(OFFICE USE ONLY)