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o�"""`s; APPLICATION FOR PERMIT TO DO PLUMBING
s 9; TOWN OF YARMOUTH
( At 4 (OFFICE USE ONLY)
By
Fee: $
PERMIT NO. e (t —� 2
Date 'd 0 !/
BuildingStitt
� /� Owner's S9&e Lo PI
AT: Location 7.T J v«►viiiv /v Name
Cu.f. YM4v23
Type of Occupancy f4%'lo&Nl lfft._
Newcr Renovation 0 Replacement 0
Plans Submitted Yes 0 No 0
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~ 0 > r O = o. 3 N 1- z O O e010 z z w re p _ BUILD NG J a
3 4 m ai c o S 3 i I-- CO U. 0 c x 3 Ce m o By
SUB-BSMT.
BASEMENT I
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name enFclmaYENTER PRISES 0 Corp.
Address 11 SCARGO HILL ROAD 0 Partnership
ULNNIS,MA 02638
508.385 1311 -§jt'Firm/Company
Business Telephone Name of Licensed Plumber R. PETER C}IECKOWA` .
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent.Check One: Yes—Ne No 0
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity 0 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 ❑ Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information I have submitted Signa of License
(or entered) in above application are true and accurate to the best of Plumber
my knowledge and that all plumbing work and Installations performed 1?
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: Master Journeyman 0