HomeMy WebLinkAboutPlumbing Permit ;�� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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Building Location wner's Name //Won, 7G/OZU
Type of Occupancy .• A .S .
New 0 Renovation 0 Replacement E( Plans Submitted: Yes 0 No 0
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S • Company Name A & B Canco Check one: Certificate
Address 350 Main Street $7 Corporation 2305
West Yarmouth, MA 02673 0 Partnership
Business Telephone 508-775-2800 ❑ Firm/Co.
Name of Licensed Plumber Doug Langtry
INSURANCE COVERAGE:
I have a currIgpt liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 1D No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy 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:
Signature of Owner or Owner's Agent Owner 0 Agent 0
I hereby certify that all of the details and information I have submitted (or entered)in ab•v• application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit if:;for this application will be in compliance with all
pertinent provisions of the Massachusetts Stats Plumbing Code a • -- •ter 142 oi+y•eneral Laws.
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SignatureTitleof License. `um•fs
Title
CitylTown Type of License: MasterLj Journeyman ❑
APPROVED( IC US ONLY) License Number 1 1 3 0 5