PP-089 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial D Residential 11''`1
Owners Name / 7. Dg R 4 Owners Address g
Building Location GAG // !/.c'(3F.o,e y /�7,tie Date //y`/f ---
New � Renovation Replacement n Plans Submitted ❑ .
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SUB-BSMT.
BASEMENT
1st FLOOR I 3- a
2nd FLOOR
R 3rd FLOOR
4th FLOOR
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5th FLOOR 4
6th FLOOR
7th FLOOR '
8th FLOOR .
Installing Company Name C J (71,t32PF/L. Check One: Certificate
Addressi �/ /0 2 B. Da /( Corp.
City WESTI'D,cT State /14. Zip Code Od 7 9 O ❑ Partner
Business Telephone: (C 79-//4/ ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter 2). ////1CAn�'
' INSURANCE COVERAGE: Chene:
I have a current liability insurance policy or its substantial equivalent. Yes No❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
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iability insurance policy Other type of indemnity Bond
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: •
Owner ❑ Agent 0
Signature of 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 the permit issued
for this application will be in compliance with all pertinent provisions of the Mas chi setts State Plumbing Code and
Chapter 142 of th en Laws. >
B y � Qp'-> \ Type License: GGG
Title _/via 2. MASTER "ignamre9 PcenPlumber
e/Town 7 JOURNEYMAN License Number //sled t�/-.5-7
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