HomeMy WebLinkAboutG-08-810G
APPLICATION FOR PERMIT TO DO GASFITTING
TOWN OF YARMOUTH By
Fee: $
(OFFICE USE ONLY)
PERMIT NO.
Date
Building n� Owner's
AT: Location 573 1.RW IS &Y QW® Name, D , 1) A%NA fC
Type of Occupancy ReS� (,j
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New �� Renovation ❑ Replacement El
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE)
Installing Company Name
Check One:
❑ Corp.
❑ Partnership
D-'FIYm/Company
Business Telephone
Name of Licensed Plumber or Gasfitter��
INSURANCE COVERAGE: Check One
I have a current liability insurance policy or its substantial equivalent. Yes 0 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 WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check One:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
1 hereby certify that all of the details and information I have submitted
(or entered) in above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed
under Permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
Signature of Licensed
Plumber or Gasfitter
S 9q -2-
License Number
TYPE LICENSE:
ElPlumber Gasfitter [� aster ❑ Journeyman