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HomeMy WebLinkAboutPlumbing Permiti an ., ; . -,i,;---=__ /O—'. 3 06) +-BAPPLICATION FOR PERMIT TO DO PLUMBING �o,` TOWN-QF.YARMOUTH �;1i Z�; 0 • •FFICE USE ONLY / OCT 1 3 I 2'ilj000 0 C T 2 5 200 Fee: $ aC/ aoS i ' EALTH DEpTPE 3MIT NO. �— I - L1 Pirly � 1 Date 19 Building i�/ Jhtil Owner's AT: Location , Name Type of Occupancy New 0 Renovation K Replacement 0 Plans Submitted Yes 0 No 0 V co co W he —1N J } V Z Z W i:c 'O a ? i:•• V� .J C ¢ m U) _ ¢ } < w a) Y CC co " a a a 3 p� 0 z O 03 W Ca Q N oC m I— W Z 0 Q M Z cc e. cc 0 `` w c=) a s 3 3 o Z i 3 14 a. 0 1- a x < cc N4 ac 7."' a f- > 1- ••O v=i ai = N 1- z o p w z z w ILA IL. v = 3 Y - m v=) c c 4 3 = < w u. 0 o 0 a 3 ¢ 4 0 SUB-BSMT. BASEMENT - )n 1ST FLOOR 2ND FLOOR 3RD FLOOR (PRINT OR TYPE) `/ j/ik Check One: Installing Coo pany Name / SL) Qijfr1jr� Corp. /`1Ad ess . © • g©)< /t9 ` \ 3� 0 Partnership . T� �" 0 Fir Company Business Telephone Ser ,/ Name of Licensed Plumber /'i`7'/`t) / (/ /9"--- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes X 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 voerage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check on Owner 0 Agent 0 r 7 I hereby certify that all of the details and information I have submitted (I 1L t �.f�� (or entered) in above application are true and accurate to the best of ignature Ucen my knowledge and that all plumbing work and installations performed Plumber under Permit issued for this application will be in compliance with all /./—/404-/f pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. License umber Type: Master Journeyman 0