HomeMy WebLinkAboutG-11-096 •
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APPLICATION FOR PERMIT TO DO GASFITTING
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a •• TOWN OF YARMOUTH By (OFFICE USE ONLY)
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.... a Fee:$
PERMIT NO. --O
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Date• I—
Building � Owner's
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AT: Location I(�PP SI Iv£e LEAF `/ Name T k� VET£C'E
Type of Occupancy 51411 L rflu4c4f
New 0 Renovation 0 Replacement CAS
Plans Submitted Yes❑ No GY
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CC x O W x u. 0 500 .-100 > 00. f- 0
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BASEMENT V „ ;.rcii s
• 1ST FLOOR
• 2ND FLOOR 4
3RD FLOOR
'(PRINT CR TYPE) Check One:
Installing Company Name In 3-E6 CY/1 0 Corp.
Address 3'5 Pcwtsnu Sian 0 Partnership
34U$Wll.l YA14. 019it" 0 Firm/Company
Business Telephone q iQ-9Z 7-G77 3
Name of Licensed Plumber or Gasfitter A4 Ties ex,a
INSURANCE COVERAGE: Check One
,1 have a current liability insurance policy or its substantial equivalent. Yes 0 No W'
II 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 M
Owner Agent ❑ss General Laws, a d th m signature on this permit application waives this requirement.
Che One:
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•
S nature of Ow er or Owner's Agent
•
I hereby certify that all of the details and Information I have submitted SignJr(or entered) In above application are true and accurate to the best of Plu er orr Gasfitter
my knowledge and that all plumbing work and installations performed T50 703
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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