HomeMy WebLinkAboutPlumbing Permit oF y�9 s APPUCATION FOR PERMIT TO DO PLUMBING
��' � TOWN OF YARMOUTH �
Z (OFFICE USE ONLY)
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A P R 2 0 2005 � Fee: $ �..�=C�
HEALTH P�- �a25?5� PERMIT No. ��_ �'S ��S�
� Date ?� 20 �3`�1
Buildi -"— Owner's �-� f���
��Q ���� AT: Locati Name
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Type of Occupancy �� �
�c�t �Uj� New❑ Renovation� Replacement❑
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��, `� Pians Submitted Yes❑ No�
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3 �c r mr�roo � 3s ►`�- n � � � oa3 $ mo
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BASEMENT
1 ST FLOOR
2ND FLt?OR
3RD FLO(?R
(PRINT OR TYPE) Ch@Gk Ot1@:
Installing Company Name t(��."?�_�ic�� ��� � Corp.
Address �i( 5,�� iQd� ❑ Partnership
,�+.� -t��2� 1'r'!�1 0��6� �fr�'"�irm/Company
Business Telephone �� E`L�-`f6G�� Name of Licensed Piumber� � 1� ��`U .
INSURANCE COVERAGE: i have a current liability insurance poGcy or its substantial equivalsnt. Check One: Yes� No ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box.
A liability insurance policy� Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIYER: I am aware that the licensee does not have the insurance voerage required by Chapter 142 of
the Mass. Generat Laws, and that my signature on this permit application waives this requirement.
Check on Owner � Agent ❑
Signature ofOwnerorOwner'sAgent
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I hereby certfty that ali of the details and infarmation t have submitted igna ure of Licensed
(or entered) in above application are true and accurate to the best of plumber
my knowledge and that all p{umbing work and instaliatians performed
under Permit issued for this appiication wfll be in compliance vaith all ;,2�J%'s�
I pertinent provisio�s of the Massachusetts State Plumbing Code and License Number
Chapter 142 of!he Qeneral Laws. Type: Master❑ Joumeyman�
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