HomeMy WebLinkAboutG-11-218 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF T -ING
yA(txruv F� .Mass. Date i a^to 2(l /D Permit 6' l 218
Building Location oilD 5 Owner's Name Jac b(tN6 0
a. �t]J \ A J Type of Occupancy nowt r=
' j .
New 0 Renovation n lace
rnentfte Plans Submitted: Yes f7 , NoM
�/e mw cL. ;CCantyo
y
•V M
\ + ,
0 '� W PI ;:' ted" t!J 0 7 tit Cil /
SUB. SEMENT
BASEMENT . F . . - _
FIRST(1ST)FLOOR. ;
SECOND (2ND)FLOOR
THIRD(3RD)FLOOR
FOURTH(4TH)FLOOR , ,
FIFTH(5TH)FLOOR
SIXTH(6TH)FLOOR •
. . -
SEVENTH (7TH)FLOOR _ i
EIGHTH(8TH)FLOOR 1,
(nst-tiling Company Name HALL OIL CO., INC. -
ssck one: Certificate +
Addre
435 ROUTE 134 SOUTH DENNISLIENNIS `�Corporation2338 C
Business Telephone 508.398-3831 . ❑ Partnership f
Name of Licensed Plwnberor Gasfitter WILLIAM H. POOLE JR ❑ Firns+Co.
ACCEPTED
INSURANCE COVERAGE: Cti
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL
Ch. 142 Yes X No C)
If you have checked,please indicate the type of coverage by checking the appropriate box
A liability insurance policy X 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 MOL.and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Owner ❑ Agent CI
I hereby certify that all of the details and information I have submitted(or entered)in above appliration are nue
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. w CO. ' r0Tt�f p ry_e„
By TyppeefLitense: pre-et,
Title 0 Plumber X Master Signature of Licensed PltunbedGasfitter
City/Town 0 Gasfitter 0 Tour eymw License Number 12879
APPROVED(OFFICE USE ONLY)