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HomeMy WebLinkAboutP-12-632�' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM � �� PLUM81NC3 WORK CITY Yarmouth DATE PERMIT#���" f32 '►�" JQBSITE ADDRESS Z2 0 So 5 I P , OWNER ADDRESS: QWNER'S NAME �C.C, C t��vC,� � t'.cw� TEL: TYPE OR pC� JPANCY TYPE FAX: Ci RIlVR�'Y COMMERCIAL ©� EDUCATIONAL ❑ RESIDENTIAL ❑ NEW: [j RENOVATION: ❑ REPLACEMENT: FIXUTRES 1 FLOORS— sum 1 2 , PLANS SUBMfTTED; YES ❑ NO I have a current Ii paky ,, Its d. INSURANCE COVERAGE i ple If you WW �*4"*k � die � of MGL Ch.142 YES ❑ have checked ,� ase ndicate the type W � 9 theapPq'oPdate box below LIABILITY INSURANCE POLICY OTHER TYPE INDEIYOW OWNER'S INSURANCE WAIVER: I am aware ❑kemee BOND ❑ Massad"4etts General Laws, and that my sig d1(M INS required by Chapter 142 of the SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ I hereby cw4 that all of the detalt and lnfortnadm I have submitted Knowledge and that all plumbing work and Installatioq>s pegformed under the (or enteged) this application aqe true and aoauaba to beat of provision of the Ma uhuslIM State Plumbing Code and Chapter 142 of the General Permit Issued bthts apgiq�tion be h pllanp al Pertine t PLUMBER NAME St.ec� LICENSE Y Z COMPANY NAME: SIGNATURE ADDRESS; STATE ® ZIP o Z y TQ; y_� _ci G FAX CELL; EMAIL: MASTER ❑ JOURNEYMAN 9--� CORPORATION ❑ # PARTNERSHIP ❑ # (�", LLC 0 #