HomeMy WebLinkAboutP-11-031 0 oF" �- APPLICATION FOR PERMIT TO DO PLUMBING
; TOWN OF YARMOUTH (OFFICE USE ONLY)
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P ... PERMIT NO. pH -- 03
Date '2/10 20/_
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AT: Location Name
Type of Occupancy Rest ct-inxt1s
New 0 Renovation 0 Replacement
Plans Submitted Yes 0 No❑
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BASEMENT
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2ND FLOOR
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3RD FLOOR
(PRINT OR TYPE) n Check One:
Installing Company Namfl kT feet' S-TCUstucL//��0� 4 3 /-7 0 Corp.
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Address I'{S EZCTd e_ ffo4O 0 Partnership
En-ST ' tcl `771A 0)-(0545- 0 Firm/Company
Business Telephone 508-9'3? 'S 7G Name of Licensed Plumber JGK S-Th2tsc^u((__
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent.Check One: Yes LS, No 0
If you have checked YES,please indicate the type of coverage by c cking 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 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 /S6 T-C
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. Type: . Master Journeyman 0