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� �F r APPUCATION FOR PERMIT TO DO PLUMBING
� �s ��g TOWN OF YARMOUTH •
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� (n� � �'s � Od � � Fee: $ ��� .�.
SEP 0 � Z� PERMIT NO. �DI- ��
'' HEA4.TH D�PT. Date�_.�8-�
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� � Building Q Owner's --_ �.1 a PS ,� M�11��
AT: Location_� � C�4n�3E�i�,/ A� _ Name •
�J�1.1 ��14'R.�.ctJ�-
Type of Occupancy �i�1►lr� f�-l-
New❑ Renovation [�' Replacement O
i
Plans Submitted Yes❑ No❑
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D � N � � a o� � _ � z 0 c9 �n a � �i
O F" W ¢ � a w m Y � a � Q a a ?+ x
AUG3 J � � WQ �n a� � a W y o � JZoaogtL �
i i-- c� = 3 = a Z = 3 Y a p F- a x Q w u. Y w �
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B y b' 3 Y m a i c o � 3 = � v�i � � � c a 3 ¢ m o
SUB-BSMT.
BASEMENT t
1 ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Ch@Ck OI1@:
Installing Company Name e,¢�/� �P �Q�'
Address_ ��—U /711�l�t/ c�'��� 7'— ❑ Partnership
� �T � ���� 0 Firm/Company
Business Telephone-- `7�75� — Name of Licensed Plumber
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes B--No ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy� Other rype of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 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 ❑ Agent ❑ '
Signature o/OwnerorOwner'sAgent �
I hereby certify that all of the details and information I have subpijtted '
(or entered) in above application are true and accurate to the best of S�9 Licensed
my knowledge and that alt plumbing work and installations pertormed P�umber
under Permit issued for this application will be in compliance with all O
pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws. License Number '
Type: Master�ourneyman❑ ;
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