HomeMy WebLinkAboutP-09-466 #87 Plumbing Permits1boy SoF367- yVdy
TOWN OF YARMOUTH
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APPLICATION FOR PERMIT TO DO PLUMBING
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Fee: $
(OFFICE USE ONLY)
PERMIT NO.
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Date Z IZ 20 G`
Building
AT: Location
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Owners E� Tip BEiQ iT/�
✓�//� Name
71417,11
Type of Occupancy
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111
Renovation ❑
Replacement ❑
Submitted
Yes ❑ No ❑
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) p ,/
Installing Company Name
Address 31 k1x.(A WS 1vy fv-
Check One:
❑ Corp.
❑ Partnership
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QP'6rm/Company ,/
Business Telephone SPY— ??Y- ��' Yl Name of Licensed Plumber f7/�'✓1 I--rJ
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes ❑ No ❑
If you have checked YES, please indicate the type of coverage bby/checking the appropriate box.
A liability insurance policy Lid' 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 ❑ Agent ❑
Signature of Licensed
Plumber
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License Number
Type: Master V Journeyman 0