HomeMy WebLinkAboutG-11-238 I 3oF'"""�q APPLICATION FOR PERMIT TO DO GASFITTING
9
N'• 4g TOWN OF YARMOUTH (OFFICE USE ONLY)
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:.'' Fee: $
PERMIT NO. 23 a
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Date i ,P-d/d
Building / n Owner's
AT: Location
Building , Owner's
4L4-4e-i30 Pc0,, Name t// 152j/
S1/464 fir t i a t.4.144
Type of Occupancy /Pew-I Si
New❑ Renovation El Replacements P
Plans Submitted Yes❑ No lie" ‘k0/
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR tf(ci;TO
(PRINT OR TYPE) / Check One:
6� 7
Installing Company Name _ Ll �.5 /6/✓ S ' '' fI Corp. _ 577
Addr ss / f6' / 'J/4/ ✓ "" /❑ Partnership
�P/✓N/5111 All vof639' ❑ Firm/Company
Business Teleph nne Jnr- .177- 3ki‘ /
Name of Licensed Plumber or Gasfitter f1/� Q9�t�<"arc//1/0 V '
INSURANCE COVERAGE: ✓/ Check ne
I have a current liability insurance policy or its substantial equivalent. Yes No ❑
If you have checked yes, please indicat the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I//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:
0/4E41ent IDSignature of Owner or Owner's Agent
41)1. 7"
I hereby certify that all of the details and information I have submitted Signature o 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 /1, 9' r1
under Permit issued for this application will be in compliance with all / !X /
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. TYPE LICENSE:
.1 Plumber El Gasfitter fatrister ❑Journeyman