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oF r ` ' APPUCATION FOR PERMIT TO DO PLUMBING
s �'g T OF YARMOUTH �o Fi � oN�Y>
��e o�,�,0 ,; ^2���� BY _
��' . �ti°°° e: $ � • -
�� �� �' PERMIT NO. �� O I - �,I
O
�� Date�T9au��o
ilding l���'� Owner's�N�« ��«- _t 1
i�; f� `� `"' � 0\1
U,_ ,.;. � ��, L �:�.' ation �_s���c�i r,���o.. Name
.al.-
�'�G`'� 3 0 � Type of Occupancy �a ,; �o,ti�K�
Ne ❑ Renovation C� Replacement❑
HEALTH EPT. itted Yes❑ No❑
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SUB-BSMT.
BASEMENT
1ST FLOOR
�ND FLOOR
3RD FLOOR
(PRINT OR TYPE) ChBCk O�@:
Installing Company Name "D L G�olc �1�,,.b�� +��ic,,.� ❑ Corp.
Address r7D ��_� U � �= ❑ Partnership
�p�'F���,-� Mclls k 1�1��1 o'Z6� l��m/Company
� BusinessTelephone yZ� �O�IZ Name of Licensed Plumber ��po�� �ok
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes ❑ No ❑
If you have checked YES, please indicate the type of coverage-by/checking the appropriate box.
A liability insurance policy I�d� Other type of indemnity � Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance voerage required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check on Owner 0 Agent ❑
- SignatureolOwnerorOwner'sAgent
1 hereby eertify that all of-ihe details and information I have submitted Signa of L nsed
(or entered) in above application are true and aecurete to the best of Plumber
my knowledge and that all plumbing work and installations performed
- under Permit issued for this application will be in compliance with all Z� �-� 6
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws.
Type: Master❑ Journeyman C3�