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; - oF Y4 APPLICATION FOR PERMIT TO DO PLUMBING
3� �;g TOWN OF YARMOUTH (OFFICE USE NLY
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D � � Fee: $ ,��
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' � , S�� o �J 2 1 � PERMIT NO.
� � ,�c� � Date ]��—
By
�D uilding ' �W� �✓�dGLi'9��
� �` � `��' � �� � G�i�� �� Name S
S E P 0 7 2001 T catio�
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�/� Type of Occupancy sNU�G L '�v4�''����/
HEALTH DEPT, eW❑ Renovation tN' Repiacement❑
I Plans Submitted Yes f� No�
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SUB-BSMT.
BASEMENT �
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name �'f'/LL1� �'������ ❑ Corp.
Address 3 ��Ma� /�!� ��N�Aw��M ❑ Partnership
rm/Company
. Business Telephone a/����.� ��4�a� Name of Licensed Plumber Q�<<- ���a
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes LK No ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy l/� 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 ihis permit applicatlon waives this requirement.
Check on Owner ❑ Agent ❑
Slgnature of Owneror Ownet's Agent
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I hereby certify that all of the details and information I have submitted Signa re of Licensed
(or entered) in above application are true and accurate to the best of Plumber
my knowledge and that all plumbing work and installations performed
ander Permit issued for this application will be in compliance with all �z G�/�2��
pertinent provlsions of the Massachusetts St�te Plumbing Code and License Numbe
Chapter 142 of the General Laws. Type: Master Journeyman❑