PP-260 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
A (Print or Type)
TOWN OF DARTMOUTH Date 34C 19 ?a2
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'e-€ = Permit #
=� Building T 4 0// GJ(C'� ' Owner ' s
AT: Location 7y- s Name rpm
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• I �/jt/Qi I QG�'�J dri c_ Type of Occupancy: g .
New LJ Renovation 0 Replacement 0
Plans
FIXTURES Submitted : Yes ❑ No El
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SUB-BSMT. _ t ■■■.
BASEMENT 1 , ■■■
-1ST FLOOR •' I I `, , I 1- ■■■.
2ND FLOOR I, I I - _ ■■■_
3RD FLOOR - ■■■
4TH FLOOR _ .....
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5TH FLOOR
6TH FLOOR ■...
7TH FLOOR _ ■ O
8TH FLOOR ■E_I
(Print or Type)
Installing Company Names 7r/ / Check On : Certificate
qS P74
r�p�� Corp.
Address / 9 G�7Nv L sb/(2D _.
0 Partnership
p/ v , rn/4 Oa-3e 0
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Business Telephone 72/7-- Oc?/ Name of Licensed Plumber
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I hereby certify that all of the detail and information l have submitted for entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed t
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.
Signature of OwnerlAgent I have a current liability insurance policy to include completed operations coverage.El r
By ,� /� '� ,6
Title Signature of Licensed Plumber
City/Town: cr-->� � lOvay of Plumbing License
APPROVED (OFFICE USE ONLY) License Number Master 0 Journeyman
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