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` .-'oF'"t-9_ APPLICATION FOR PERMIT TO DO PLUMBING
a0r t TOWN OF YARMOUTH
(OFFICE USE ONLY)
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-"r„,.," D Fee: $
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,r4-0,BY PERMIT NO. ��— (o( I
SUIWING DEPT Date _ 20 /
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Building Owner's _ VIL�1
AT: Location_ItG G VIA
eV aCS Name
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1.7 Type if occupancy \) %, j_(I (t;,..,_
New Renovation ❑ Replacement ► ���
Plans Submitted Yes❑ No❑ —
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SUB-BSMT.
BASEMENT % G
1ST FLOOR ^Q
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) 1^{ Check One:.
Installing Company Name LaUV1-{ �B�tAtt.-v ❑ Corp.
Address l9 1 /�n tto FWet
—�t-,k1t-P 0 Partnership
tAklaU f S Wt o z6oi ❑ Firm/Company
Business Telephone 529Q 77D LI fIIrn3ofLicensed Plumber
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes 0 No 0
If you have checked YES, please indicate the type of coverage y ch ing the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond 0
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 0 Agent ❑
Signature of Owner or Owner's Agent li�p� r�[/
I hereby certify that all of the details and Information I have submitted ,p � �ature of Licensed
(or entered) in above application are true and accurate to the best of Plumber
my knowledge and that all plumbing work and installations performed /_
under Permit issued for this application will be In compliance with all 0
6
pertinent provisions of the Massachusetts State Plumbing Code and License N mber
Chapter 142 of the General Laws. Type: Master Journeyman 0