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APPLICATION FOR PERMIT TO DO PLUMBING
TOWN OF YARMOUTH (OFFICE USE ONLY)
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PERMIT NO. P-0/—
Date
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New ❑ Renovation ❑ Replacement
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE)
Installing Company Name F F'.1,)1r &JiN)?4-N cr�•
Address a PEE G (l n I t s _I E
Business Telephone
Check One: I
Corp. nU - Z.�646 I ` r,
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❑ Partnership
❑ Firm/Company
Name of Licensed Plumber -P" -F �IIN iU f) ,L�
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes P 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.
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted
(or entered) in above application are true and accurate to the best of
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
Chapter 142 of the General Laws.
Check on Owner ❑ Agen ❑
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/ Signature of Licensed
Plumber
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License Number
Type: Master Journeyman 0