HomeMy WebLinkAboutG-11-270 „,,, of""""p:--- APPLICATION FOR PERMIT TO DO GASFITTING
;g TOWN OF YARMOUTH By (OFFICE USE ONLY)
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PERMIT NO.& f 1 -270
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Building Owner's 19 g1-43H-e-
AT: Location 7b Sea�r o)tl WCC1 Name K i'1eV1 f+tL !J
Sc,ur-r-) yavfvt,/t trrt 6-4.-dType of Occupancy
News Renovation 0 Replacement 0
Plans Submitted Yes 0 No C3
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SUB-BSMT.
BASEMENT
1ST FLOOR X
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) (� Check One: ACCEPTED
Installing Company Name vtoti3' f t" u-t11�1 MP\ �i { ❑ Corp. e
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Address 90 A eix 3 el 0 Partnership
Vanst 8con sm-tok% Mw a3��� g Firm/Company
Business Telephone 6na ,-7 F`1) ( f '
Name of Licensed Plumber or Gasfitter e- H Si-I VIA)
INSURANCE COVERAGE: Check One
I have a current liability insurance policy or its substantial equivalent. Yes E4 No 0
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy IX 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:
Ow r A ent
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 of Licensed
(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 /✓2 /0'701^
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:
CiPlumber 0 Gasfitter pfMaster 0 Journeyman