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APPLICATION FOR PERMIT TO DO GASFIiTING
OFFICE USE ONLY)
—:A� \ TOWN OF YARMOUTH By 012._142)1(
Fee:$ lo-a)
PERMIT NO.
Date `1 / p/.2 l t
Building 014 Owner's
AT: Location oW 'own Howe. ILL Name G..cc" faint 5
11t5 re-hait, , *IA NC)) Lf CS
jype of Occupancy /
New❑ Renovation 0 Replacement Qe
0 t.,\ Plars Submitted Yes❑ No❑
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14
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00012
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name r/e.A- .( irnVirooi t'S 0 Corp.
Address �"& 196n-CS - St 0 Partnership
y
" r S rrJ JTh.—, n119 O,2C1 ) 0 FirnVCompany
Business Telephone Sol— Jfl' T71 '
Name of licensed Plumber or Gasfitter crm.s.Y' 17 K'✓
INSURANCE COVERAGE: Check One
I have a current liability insurance policy or its substantial equivalent Yes XI No 0
If you have checked yes,please Indicate the type of coverage by checking the appropriate box.
A liability insurance policy 2' 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:
Owner ❑ Agent ❑
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 or Gadtter
my knowledge and that ail plumbing work and Installations performed . 3071 r
under Permit Issued for this application will be In compliance with all Asa Number
pertinent provisions of the Massachusetts Stats Plumbing Cods and
Chapter 142 of the General Laws. TYPE LICENSE:
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