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� Y � � APPLICATION FOR PERMIT TO DO PLUMBING
�� �;g TOWN OF YARMOUTH (OFFICE USE ONLY)
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Fee: $ a�d•��
; PERMIT NO. � bQ'a��
Date �2 19 �
Building Owner's � �'� �Q t
AT: Location �A � S� Name �� T�
Type of Occupancy S� �C�L� '}^
New❑ Renovation ❑ Replacemeni�]�
' itted Yes❑ No O
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name �A�"� �-� ❑ Corp.
Address�� v� S�Z ❑ Partnership
' �.-fLr' S -^A"t}�-` O Firm/Company �-----'��
Business Telephone ���' �� �� Name of Licensed Plumber��b�1�� T��1,�'�
INSURANCE COVERAGE: I have a current liabiliry insurance policy or its substantial equivalent. Check One: Yes�❑ No ❑
If you have checked YES, please indicate the type o#coverage by checking the appropriate box.
- A liability insurance polic�— Other type of indemniry ❑ 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 on this permit application waives this requirement.
Check on Owner ❑ Agent ❑
Signatu�e of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted 1 -
Signature of Licen ed
(or entered) in above application are true and accurate to the best of Plumber
my knowledge and that all plumbing work and instaflations performed
under Permit issued for this application will be in compliance with all � '� ��
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. Type: Master❑ Journeyman�
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