HomeMy WebLinkAboutPlumbing s"oFd_--y ����y i • APPLICATION FOR PERMIT TO DO PLUMBING
44,
,.3. , -4( kt; TOWN OF YARMOUTH
" (OFFICE USE ONLY)
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;: 51"�•''° ' Fee: $ --. 1i
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PERMIT NO.
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Date !f_* 20 Cif
Building Owner s
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AT: Location qc e—/ 0 C.� Name
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Type of Occupancy
New E Renovation VI Replacement❑
Plans Submitted Yes❑ No❑
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SUB-BSMT.
BASEMENT L
1ST FLOOR -
2ND FLOOR _ _
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name / T ,i)oz:7 7g..a. ❑ Corp.
Address '6` ' '
I 6)X .c9a"2 ❑ Partnership
C Firm/Company f - ie& 1X'C? ,
Business Telephone -"C)S �' ?,S= 66 70 Name of Licensed PlumberOMAC `5 4 i1' Keg R/R
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes Er No ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
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.
Check on Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
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
my knowledge and that all plumbing work and installations performed
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: Maste • Journeyman 0