HomeMy WebLinkAboutPlumbing Permit 1
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; � �F rq,�; ' ARRLtGA'�fpN FOR PERAAtT TO d0 FLU�If�tNG
i g TOWN OF YAR�O�TH
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8uiiding �. � Owner's ����
AT: Locatiort � . - ,=s ' Name '' � ; �
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� Type of Occupancy ��'�� ,
New� Renovation � Replacement❑
Plans Submitted Yes❑ No❑
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BASEME �
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, i ST FLOOR
2ND FLOOR
. 3RD FLOOR
�PRwr oR TVPE� Check One:
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fnstalling Company Name , � � � ��p
Address .�°�"��-� � ,�,r �
--�--,--� ❑ Partnership
r '' irmfCompany
Business Telephone��� --� ��5.�_ Name of Licer�sed Plumber � �., "��,� d�
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1NSURANCE COVERAGE: I have a current tiability insurance policy or Rs su6stantial equivalent. Check One: Yes � No ❑
If you have checked YES, please indicate the type of coverage by ct�cking the a�propriate box.
A liability insurance policy�1l Other type of indemnity ❑ gon� ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does no#have the insurance uosrage required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check on Owner ❑ Agent ❑
Signature ofOwnerorOwner'sAgent ` s
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1 hereby certify that ail of the details and in#ormation 1 have submitted Signature of Licensed
(or entered) in above application are true and accurate to the best of Plumber
my knowledge and that all plumbing wark and instaliations pertormed
under Permit issued for this applica#ion v�rill be in compliance with ali �,r`� ��� �
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws.
Type: Maste� Journeyman❑