HomeMy WebLinkAboutPlumbing Permit r=_ r _ - y APPLICATION FOR PERMIT TO DO PLUMBING
' ' .. -111r TOWN OF YARMOUTH (OFFICE USE ONLY)
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G�3 G �'i , Fee: $ I S e
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PERMIT NO. — (}(? ” /jrf-.
P 3,,,,7:
EALTH DEPT. Date Vi"-- 20 a E
Building Owner's !f'� i^ + y
AT: Location Name
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New CI Renovation ReplacementOcupancy /�-�
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Plans Submitted Yes❑ No❑
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BASEMENT r
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name ,M 14:1, A
C ' 6,-A-5.4 s1p(s �r+81,E s ❑ Corp.
Address [Sri ,"--e-f4,"--e-f4 ' S i ❑ Partnership
Derrov i'S P°P-f . Al A Vi Firm/Company
Business Telephone g? 4- 736 X Name of Licensed Plumber 'n ' C N A t -
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes` ' No ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance polis? Other type of indemnity CI Bond ID
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 on Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted cl: 4----a e of L -/fed
(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 (, 3 ..`R
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. Ty•
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