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MATTACHEESE
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APPLICATION FOR PERMIT TO DO PLUMBING
TOWN OF YARMOUTH
(OFFICE USE ONLY)
By
Fee: $ 4z 0 'cz
PERMIT NO. P -O /— 715
Date 1:9
Building Owner's Cwfli�sL6n2jij
AT. Location IV LN Name:�". ���
Type of Occupancy Iffildb-ye,
New ❑ Renovation ❑ ReplacementKI
Plans Submitted Yes ❑ No ❑
(PRINT OR TYPE) Check One: ' I I �, 2
Installing Company Name F_F w �( Xo �Q Corp. Qu -ZQj` 61
Address —ATEGI b� i rC ��, ❑ Partnership
S---���' '+ —7—� �7 ElFirm/Company
Business Telephone —:M8- !M8 Name of Licensed Plumber i"- w IRSIOI l
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes A-1 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 voerage required by Chapter 142 of
the Mass. General Laws, and that my signature- 41 °S ^��nlication waives this requirement.
Signature of Owner or Owner's nt
FEB z 8 2001
v �o1f160
1 hereby certify that all of the details and tan
matron I have submitt d
(or entered) in above application are true f
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.
Check on Owner ❑ Agen ❑
Signature of Licensed
Plumber
�q3G
License Number
Type: Masteo� Journeyman ❑
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One: ' I I �, 2
Installing Company Name F_F w �( Xo �Q Corp. Qu -ZQj` 61
Address —ATEGI b� i rC ��, ❑ Partnership
S---���' '+ —7—� �7 ElFirm/Company
Business Telephone —:M8- !M8 Name of Licensed Plumber i"- w IRSIOI l
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes A-1 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 voerage required by Chapter 142 of
the Mass. General Laws, and that my signature- 41 °S ^��nlication waives this requirement.
Signature of Owner or Owner's nt
FEB z 8 2001
v �o1f160
1 hereby certify that all of the details and tan
matron I have submitt d
(or entered) in above application are true f
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.
Check on Owner ❑ Agen ❑
Signature of Licensed
Plumber
�q3G
License Number
Type: Masteo� Journeyman ❑