HomeMy WebLinkAboutG-13-432 •
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•oF_` -_ APPLICATION FOR PERMIT TO DO GASFITTING
? *9;g( OFFICE USE ONLY)
TOWN OF YARMOUTH By
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Fee:$
E�� Nil PERMIT NO. 13— 32
G01 20 2012 Date v—
Buildin. Owner's /�
AT Locatio IA t,,.; . I'PTS Name Chris tf�
Type of Occupancy Z- 3 .
New❑ Renovation 0 Replacement 91
Plans Submitted Yes 0 No❑
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SUB-BSMT.
• BASEMENT
1ST FLOOR f / /
2ND FLOOR
3RD FLOOR
ACCEPTED An-
(PRINT OR TYPE) Check One: By:
Installing Company Name f(C/V S P ❑ Corp.
Address ‘ / 440474 /•( EG-/I/5 Rye- 0 Partnership
AGv5/1 /FVCr M A G"fimv'Company
Business Telephone yE, 7 Po 03 r/
ccit,S-68 ?X' /Z 59 K EN G R� l/ES o /V
Name of Licensed Plumber or Gasfitter
INSURANCE COVERAGE: Check One
I have a current liability insurance policy or its substantial equivalent. Yes 0 No 0
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy 0 Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of
the Mads General Law and that my signature on this permit application waives this requirement.
Check One:
Owner �f Agent 0
Signature of Owner or Owner's A nt
I hereby certify that all of the details and information I have submitted Signature of Licensed
(or entered) in above application are true and accurate to the best of Plumber or Gasfitter
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 License Number
Chapter 142 of the General Laws. TYPE LICENSE:
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