HomeMy WebLinkAboutG-03-046MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO // S TNG / 4
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(Print or Type)
Mass. Date 19
City, TownVVj
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Permit # U3 — 6Y
Owner's ✓
Name
Type of Occupancy: /
New ❑ Renovation Replacement ❑
P ❑
�-,t+s Submitted Yes ❑ No
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(Print or Type)
Installing Com
Address
Business
Check One: Certificate
Na*440& t*- &A!f Af (e St Corp.4�'0;�'� �
❑ Partnership
❑ Firm/Company
Name of Licensed Plumber or Gasfitter
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1 hereby cattily that as 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 as plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I.. have informed the owner or his agent that I do not have liability insuranceincluding completed operations coverage.
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1 have a,currenrliability insurance policy to include completed operations coverage. MO
aI By
19 Title
City/Town
TYPE LICENSE:
❑ Plumber
❑ Gasfitter
Master
❑ Journeyman
Signature of Licensed
Plumber orGasfitter
73%-
License Number
a0 TOWN OF YARMOUTH
a Building Department
' Town Hall
Yarmouth, MA 02664
(508) 398.2231 ext.261
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Building Location:
Owner's Name:
Owner's Address:
Owner's Telephone:
Gasfitter Name:
License Number:
Company Name:
Company Phone:
PERMIT TO DO GASFITTING WORK
Recorded By:
PERMIT NO.
Permit Fee:
Payment Type:
Check Number:
Issue Date:
Type of Work:
Comments:
(OFFICE USE ONLY
INSPECTION RECORD
Date Note Progress - Corrections and Remarks Inspector
i Date Printed: 5/16/02