HomeMy WebLinkAboutP-13-221 _� APPLICATION FOR PERMIT TO DO PLUMBING
mo • g TOWN OF YARMOUTH (OFFICE USE ONLY)
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Fee: $ `IOOZI
iPERMIT NO. / I g— ag
!_ 3 I^y, Date/6-1 2012
.1 Building j .,,, PC{/1a in i Owner's Y►'/CtArit ejlC`
J AT: Location
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Typefccupancy
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N" New❑ Renovation ❑ Replacement
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r = _;^� laps Submitted Yes No El
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0 SUB-BSMT.
,1/4„0„1/40 BASEMENT c
�1J 1ST FLOOR
I 2ND FLOOR
1� 3RD FLOOR
(PRINT OR TYPE) . •'- . G Check One:
Installing Company Name�/ � ` eA ❑ Corp.
Address Li V Y Mg Q (tP, P ID Partnership
ASAAIlNl S Y`n Ce O >,6 O l 0 Fit/Company
Business Telephone S )8 775 yi 73 Name of Licensed Plumber LCOLA, � � k-CaCk
S INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent. Check to �ne: Yes it./No El
3 If you have checked YES, please indicate the type of coverage by chec ''ng the appropriate box.
A liability ihsurance policy LU/ Other type of Indemnity ❑ Bond ❑
O 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 0
Signature of Owner or Owner's Agent
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
my knowledge and that all plumbing work and Installations performed r� l
under Permit issued for this application will be In compliance with all
06
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. Type: Mastery( Journeyman❑