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HomeMy WebLinkAboutG-11-642 - oR�' �'_ APPLICATION� FOR PERMIT TO DO GASFITTING ? �; S NLY) \?>. B�P,IO� U� • TOWN OF YARMOUTH \Y�Ti1CME¢ - Fee: $ /� ;, Q ,'' PERMIT NO. —1 ( -Ceti Q GDate Building 6-59 /tow Sr. Owner A AT: LocationName me s yAQ,rc/f/J NA Type of Occupancy 4 4'//Gcz./U7/At-- New❑ Renovation TO . Replacement 0 Plans Submitted Yes❑ No❑ IWI _ CCN U) la �� N Se f/l U Z ix 0 R ypeat _ _. _.__ ' —Me- ° CO _.. W to O U O fA S F� b. W ul Qcc > m > ZZ Q J F- I- tz 0 W O y =r ! m czO LLD0aaU2 > o. W oS CJ O SUB-BSMT. BASEMENT / / / 1ST FLOOR 2ND FLOOR 3RD FLOOR (PRINT OR TYPE) Check One: Installing Company Name / — 0 Corp. Address /3 /u/e'E•1&M7W 0 Partnership 2I, h/,a /7' 1 A ©2.113 M Firm/Company Business Telephone ef liVOTh 9 a2 28-ce Name of Licensed Plumber or Gasfitter ,4 . INSURANCE COVERAGE: Check One I have a current liability insurance policy or its substantial equivalent. Yes 21 No 0 If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy 0 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: • /,OJwnerr 0 Agen . Signature of Owner or Owner's Agent11�/%`9 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 Gasfitter my knowledge and that all plumbing work and installations performed 47b84 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 LICENSE: