PP-500 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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TOWN OF DARTMOUTH Date 9 - H H 19
T �� Permit #
=' Building Owner 's
AT: Location / 2.I {' i Name 1-0 bhp
�,// Type of Occupancy: ices
New El Renovation EI Replacement 0
Plans
FIXTURES ❑
Submitted: Yes El No
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SUB-BSMT.
BASEMENT
1ST FLOOR l \ �``
2ND FLOOR , a
3RD FLOOR
4TH FLOOR
5TH FLOOR
l 6TH FLOOR
7TH FLOOR
8TH FLOOR
(Print or Type)
Installing Company Name �'(;v� �dUL Check One: Certificate
r� ❑ Corp.
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Address 4i'U Lt_ "v .Q 0 Partnership
❑ Firm/Company
Business Telephone <2j0 3 L" Name of Licensed Plumber
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I hereby certify that all of the detail and information I have submined(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.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. te
• Signature of Owner/Agent I have a current liability insurance policy to include completed operations coverage.❑
By
Titl Signature of Licensed Plumber
'SSW/Town: T gee ((o]]f�� Plumbing License
iti APPROVED (OFFICE USE ONLY) License Number 0 Master u Journeyman
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