HomeMy WebLinkAboutG-10-414 OF,,,,,_ APPLICATION FOR PERMIT TO DO GASFITTING
r H (OFFICE USE ONLY)
~3 x TOWN OF YARMOUTH By
- iur*�eese ��\,
Fee: $ c-vuv
PERMIT NO. 4/0 iffy
G.
F3n
I +
Vf
Date /7 de?
Building Owner's
AT: Location?: o11:0
Name � d /!�4/�C /C /juCe
D�Type of Occupancy fZ3�I1S�INew / Reon ❑ lat❑
W , o �ns1$ubmitted Yes El No❑
, cW. tz0cP-z -2L 2o
•
cc co
_ w J FK
m 0 F W .-: = cp
1-
2 Z O W W
p, Oa
N 0 0 U W_ = N W N1' O p > W
0 I- Z J wee co w H Z W W re Ce O Iii O 7 LL F U J N W
z W > K W re z < >- < 00 0 00 w 00 w 2
= O O = u. 7 3 o O J a 2 > o o- f- O
SUB-BSMT.
BASEMENT
1ST FLOOR X
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Chep One: / 3
Installing Company Name LS Corp.
Address H. H. SNOW & SONS, INC. 0 Partnership
22 MAIN STREtT
ORLEANS, MA 028.4 0 Firm/Company
Business Telephone /— ra F ZS,�/G 9 6
Name of Licensed Plumber or Gasfitternaia/L ' 1_,- ge'/'ve---"
INSURANCE COVERAGE: Check One
I have a current liability insurance policy or its substantial equivalent. Yes 0 No El
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 La s, an hat my signature on this permit application waives this requirement.
Check One:
Owner ❑ Agen
Signature of Owner or Owner's Agent
CaWilian5
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 11(1/92 71
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:EN'
0 Plumber L13"Gasfitter LyMaster 0 Journeyman