HomeMy WebLinkAboutP-12-305 I • a
0 r APPLICATION FOR PERMIT TO DO PLUMBING,
Int%• TOWN OF YARMOUTH (OFFICE USE ONLY)
r;h By
Fee:
PERMIT NO.I12 "3 O
Data
BuildingOwner's D'n/10.
AT: Location I b � r)1� n S I Name
Type of Occupancy oStc can r
New❑ Renovation 0 Replacement,$
Plans Submitted Yes 0 No❑
1I L H .. 132511 11
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o �Vy� yy�� LL
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y 110111101 ,
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p a I3ob t3 '
SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR _
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Comm Name i.'/ IfeCorp. 3,77S
Addre— 1 •- /.. -'Z 0 Partnership
e`7 0 Firm/Company
Business Telephone Name of Licensed Plumber
INSURANCE COVERAGE:I have a current liability insurance policy or Its substantial equivalent.Check One: Yes No 0
If you have checked YES, please Indicate the type of coverage by checking the appropriate box.
A liability Insurance policy 0 Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance vicerape required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Che n Owner 0 Agent 0
Signature or Owner or Owner's Agent •
I hereby certify that all of the details and Information I have submitted r Signe. 'e of Licensed
(or entered) In above application are true and accurate to the best of Plumber
my knowledge and that ail plumbing work and Installations performed �� Si)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: Mastery Journeyman 0