HomeMy WebLinkAboutG-12-195 st. ( + ,� NMASSACHUSETTS-UNIFORMAPPIICATIONFOWPERMRTCDO-GASTITTFRG
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�V 'tit, 7 44, yYarmouth MA. Date: 10/0611 Permit# 012 - t e 15-
Building Location: 65 Union Street M#115P#60 Owners Name: Ellicott
Type of Occupancy: Commercial ❑ Educational ❑. Industrial 0 Institutional 0 Residential IQ
b 1 New: 0 Alteration: 0 Renovation: 0 Replacement: I, Plans Submitted: Yes 0 Nog]
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Check One Only CertifiEatf
Installing Company Name: Hall Plumbing& Heating, Inc.
aEorporation C-2803
Address:447 Old Chatham Road City/Town: South Dennis State:MA
❑Partnership
Business Tel: 508-385-9127 Fax: 508-385-6604
❑Firm/Company
Name of Licensed Plumber/Gas Fitter: James Pazakis
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes 51 No 0
If you have checked Yes,please Indicate the type of coverage by checking the appropriate box below.
A liability insurance policy ®- 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 tht
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box I_k 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 .ws.
type of License:
gy tleej Plumber
Iry
TiLI Gas Fitter
(a-Master - lc •er/Gas Fitter
City/Town
❑Joumeyman -
El LP Installer
•ense Number: PL-15030-M
PP.RQYEOlQFF10E.StSE ANi.Y!