HomeMy WebLinkAboutP-12-123 a ,, AWLIt:AI IUN FUR PERMII IU UU numesinu
cifilfiti TOWN OF YARMOUTH (OFFICE USE ONLY)
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Fee:$ (10,0-9
PERMI
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PERMIT NO.
Date
Building4irr.t_� owners r✓cs - AI)G'
AT: Locatiorot, I tiLSG �Z Name
V�fr \/wrraaA, , Intl 0)42) S
Type of Occupancy aC
• New 0 Renovation 0 Replacement/la
❑ Flans Submitted Yes 0 No❑
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SUB-BSMT.
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BASEMENT 3.
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name flrf,Lys p/via,; t 0 Corp.
Address r, ,CGnS 5,7 c r 0 Partnership
/2i'Cx.s'S'er-. H'J1Q /1]..G'3 ) 0 Firm/Company
Business Telephone Poi- in7, ("23 5 Name of Licensed Plumber. )hroti des"
INSURANCE COVERAGE:I have a current liability insurance policy or Its substantial equivalent.Check One: Yesy No 0
If you have checked YES.please indicate the type of coverage by cheddng the appropriate box.
A liability insurance potky9' 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 tilos permit application waives this requirement
Check on Owner 0 Agent 0
Signature of Owneror0anertrAgent
I hereby certify that all of the details and information I have submitted Sigto : 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 ) ` d02/r
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. Type: Master 0 Joumeyman.W