HomeMy WebLinkAboutP-11-267 AF"" r;---- APPLICATION FOR PERMIT TO DO PLUMBING
b"le - •q; -_, TOWN OF YARMOUTH (OFFICE USE ONLY)
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\"'+i=-,',. Fee: $ 6 �x^Q Grit
P PERMIT NO.
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Date t tilt 20 to
Building Owner's .rub' &e LA4.V
AT: Location 9 2 Sc4bw Aµc Name
Type of Occupancy tt-'irrl¢4.0
New 0 Renovation 0 Replacement lve
Plans Submitted Yes❑ No❑ •
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RECEIVED
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SUB-BSMT.
BASEMENT St
1ST FLOOR
2ND FLOOR
3RD FLOOR
ACCEPTI
(PRINT OR TYPE) Check One: Wyj
Installing Company Name t"D Rk.+4,1 ivi 0 Corp.
Address 10 Su SF,) (ky,;F t-t 0 Partnership
`9t t0t5emrf i tvtif ` Vo3`f 0 Firm/Company Der
Business Telephone 174-1-1t-22-60 Name of Licensed Plumber Sit" _ ft"'"`
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes ria No 0
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy Fl Other type of indemnity D Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance voerage required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check on Owner 0 Agent 0
Signature of Owner or Owner's Agent
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
my knowledge and that all plumbing work and installations performed
under Permit Issued for this application will be In compliance with all 5380iP
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws.
Type: Master 0 Journeyman