HomeMy WebLinkAboutG-12-465 ov`"r APPLICATION FOR PERMIT TO DO GASFITTING
tem (0F7CE USE ONLY)
44 TOWN OF YARMOUTH By , q •
G . Fee:$ 0111
PERMIT NO.
Date N I ZO I Z
Buildingn Owner's
AT: Location �j w 1 G- '.fl n QO� Name
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Type of Occupancy (2 '61GU-n414I
so ^ . New 0 Renovation 0 Replacement'
/J„ zl P{ans Submitted Yes❑ No
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SUB-BSMT.
BASEMENT i
1ST FLOOR
2ND FLOOR
3RD FLOOR •
(PRINT OR TYPE) Check One:
Installing Company Name NA G>0n n e 1\1 Mei btry</_ L9 Corp.
Address -1 q &loco; $-4,ree k. 0 Partnership
\flit'Sk- Den nitS MA O21o10 ❑ Firm/Company
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Business Telephone Qs •3?4 •coos
Name of Licensed Plumber or Gasfitter JIM me-bonnet}
INSURANCE COVERAGE: Check One
I have a current liability insurance policy or its substantial equivalent. Yes ® No 0
If you have checked yes,please indicate the type of coverage by checking the appropriate box.. •
A liability insurance policy pa 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 On
Own: II 'gent 0
Signature of Owner or Owner's Agent
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I hereby certify that all of the details and information I have submitted qr/,of-Licensed
(or entered) in above application are true and accurate to the best of rx Gasfitter
my knowledge and that all plumbing work and installations performed 5 _
under Permit Issued for this application will be In compliance with all -
pertinent provisions of the Massachusetts State Plumbing Code andLicense Number
Chapter 142 of the General Laws. - TYPE LICENSE:
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