HomeMy WebLinkAboutBLD-19-4337 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
\JA4MuJ)C�..1 Mass. Date /1 / ? 2011 Pamit4Qr ` _ -
B ding Location /2 I.3/!/-4 f ,iJ 7�G �9/f/f11it/�1��
,'^ _, Owner's Name (Enrt9/— (1, 'Typee Occupancy RESIDENCE
. . NewRenovation Q Replacements Plans Submitted: Yes Q No)8(
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BASEMENT 1
re ` EMENT ..o L, � "T(1ST)FLOOR X
c f ( OND(2ND)FLOOR 0
F. ! t r e (3RD)FLOOR
1 0 0 •ita URTH(4TH)FLOOR
•4 (5TH)FLOOR
�+ (6TH)FLOOR
o 'SEVENTH(7TH)FLOOR
. . . . .
EIGHTH(8TH)FLOOR
Installing Company Name HALL OIL CO, INC. 4
Addresste
435 ROUTE 134 SOUTH DENNIS Check X Corpor: Cerri38 Cocarion 2338 C
Business Telephone 508398.3831 ❑ Partnership
Name of Licensed Plumber Of Gasftter WILLIAM H. POOLE JR ❑ Fimv'Co.
D.SLTRANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL
Ch. 142 Yes X No❑
If you have checked m please indicate the type of coverage by checking the appropriate box. '
A liability insurance policy )Z( Other type of indemnity 0 Band 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 0 Agent ❑
I hereby certify that all of the details and information I have submitted(or entered)in above application are true
and accurate to the best of my knowledge and that all phrmbing 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.
By Type aliment
Title ❑ Mut Mast Signature of Licensed PhuattewC cf tter
City/Town ❑ Gashua ❑ Journeyman License Number 12879
APPROVED(OFFICE USE ONLY)