HomeMy WebLinkAboutP-11-084 APPLICAIIUN FUR PERMIT I U UV rLuMolNu
�+ %_ TOWN OF YARMOUTH (OFFICE USE ONLY)
By
Fee: $ CSC(PERMIT NO. I/ --- OU/7
Date a^/l 20 ltd
Building Owner's ....141A/ V£7fr7{
• AT: Location ((Os S�/.-�/£2- 1 AF Name
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Type of Occupancy 6-11-frer TAH„
iti
New 0 •Renovation 0 Replacement
Plans Submitted Yes❑ No❑
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SUB-BSMT. -1 c, k . '��
BASEMENT ✓ F 4t':--- '--
1ST FLOORAL� e 10`�
2ND FLOOR 3RD FLOOR ALMWI, Lail
1-,o`" ,o`v, _
(PRINT OR TYPE) Check One:
Installing Company Name /Nice- CyIL 0 Corp.
Address 'SS PtAr2SC& SWEST ❑ Partnership
r5`em4'R-Lc �4. 01S /r
0 Firm/Company
' Business Telephone 9*S47-6723 Name of Licensed Plumber I#- - lye?
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent.Check One: Yes 0 No Q-
• 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 coverage required by Chapter 142 of
the Mass 1 eral Laws, and that y1.ignature on this permit application waives this requirement.
al, _ I J/ / Check on Owner 2 Agent 0
Signa 're of 0 erorOwner'sAgenf (/y
VAC
I herebycertify that all of the details and information I have submitted /l� l/
N Signature of Licensed
, .(or entered) In above application are true and accurate to the best of Plumber
t my knowledge and that all plumbing work and Installations performed T�O��
under Permit Issued for this application will be in compliance with all J
pertinent provisions of the Massachusetts State Plumbing Code and License Number
chapter 142 of the General Laws.
Type: Master 0 Journeyman LT