HomeMy WebLinkAboutG-12-080 "oF 9_ APPLICATION FOR PERMIT TO DO GASFITTING
~3 ;4 TOWN OF YARMOUTH By (OFFICE USE ONLY)
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Fee: $
NO.0PERMIT I2 —ORO
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Building Q � Owner's A ���
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Type of Occupancy /1.5 42
New 0 Renovation 0 Replacement 12— C
Plans Submitted Yes❑ No Er 0/
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SUB-BSMT.
BASEMENT
1ST FLOOR /
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) _ _ Check One:
Installing . 3G' s Plumbing & Heating,. Inc. f Corp. �7C
Corr . 188 Main St. Rte. 28
Address
s—_- Dennisport, Ma." 02639 ` 0 Partnership
508-398-3846 _ _ __ . __ . _ ___ i 0 Firm/Company
Business Telephone /�
Name of Licensed Plumber or Gasfitter , h ( 1/41(97 rJ0ei4 t-1/€INSURANCE COVERAGE: l Check One
I have a current liability insurance policy or its substantial equivalent. Yes,ES No 0
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy p 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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I hereby certify that all of the details and information I have submitted Signature is sed
(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 FM:2
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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tuber 0 Gasfitter/0 Master 0 Journeyman