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` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
_ ( y City/Town:Yarmouth MA. Date: 10/06/11 Permit# w - in
Building Location:65 Union Street M#115P#60 Owners Name: Ellicott
PType of Occupancy: Commercial ❑ Educational ❑ Industrial❑ Institutional ❑ ResidentialX
New:❑ Alteration: ❑ Renovation: ❑ Replacement:gj Plans Submitted: Yes ❑ Nog
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Check One Only ertificate •
Installing Company Name: Hall Plumbing&Heating,Inc.
■ Corporation 42803
Address: 447 Old Chatham Road City/Town: South Dennis State: MA ❑ partnership
Business Tel:508-385-9127 Fax:508-385-6604 0 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 gl No 0
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy g 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 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 ,•• ation will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Gen- •ws.
By Type of License: 41,
Title EI$Plumber • • . ere of Licen d Plumber
City/Town 3Master Lice - •mber: PI-15030
APPROVED(OFFICE USE ONLYI , Uourneym•.•