HomeMy WebLinkAboutG-13-271 "••p • _, i ,• APPLICATION FOR PERMIT TO DO GASFITTING
EAI E I ' (OFFICE USE ONLY)
_, I = TOWN OF YARMOUTHL
By /2 II.
•
Fee: $ liQ Un
PERMIT NO. (�i3 ' 87/
Date a♦n /
Building
I6 2 Run
Un n�J RCJ Owner's L 0J
GAT: Location J { Name � Q U0JIr
ype of Occupancy Owed I i ti C
New 0 Renovation 0 Replacement r
',liens Submitted Yes 0 No❑
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SUB-BSMT.
BASEMENT
M M 1ST FLOOR
-
0 2ND FLOOR
1/431k ka 3RD FLOOR
•
C (PRINT OR TYPE) 1 �. Check One:
Installing Company Name/�nrak ASW. 0 Corp.
Address 4� `� 't t• t L° �/�. ❑ Partnership -
t+MQt s Vila la Q Z� 0 Firm/Company
te, L7— Business Telephone 50 5087 7c 1113
3 Name of Licensed Plumber or Gasfitter cimm
C3eiVVka
Q INSURANCE COVERAGE: Check 05.e
I have a current liability insurance policy or its bstantial equivalent. Yes l No 0
If you have checked yes, please indic tet pe of coverage by checking the appropriate box.
A liability insurance policy 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check One:
Owner 0 Agent 0
Signature of Owner or Owner's Agent
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ic
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 1 I 0 6
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 LICEN :
0 Plumber 0 Gasfitter L/SMaster 0 Journeyman