GP-215 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
TOWN OF DARTMOUTH date �`, /7 19 � /
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� �� ( Permit #k Y J
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�` AT: Location (� �rAi L�rrl , DRName__� C�/Z
Type of Occupancy: 1�2_
New Q Renovation 0 Replacement El
Plans Submitted Yes ❑ No in
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6TH FLOOR
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(Print or Type)
Check One: Certificate
Installing Company Name / io L;h/ �j>/ 7:-to ® Corp.
Address id/. C d(Jt C �- _ ❑ partnership
h� SJ7tq __ 0 Firm/Company
Qa Business Telephone 6. 7 G 1 7 (J S Name of Licensed Plumber or Gas Fitter
I hereby certify that all of the detail and information I 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
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 Owner/Agent I have a current liability insurance policy to include completed/operations coverage.El"-------
By , TYPE eICENSE:
Plumber _ Lam/
Titl ' ma
a Gas Fitter Signature of Licensed
City/Town: - v Master Plumber or Gas Fitter
APPROVED (OFFICE USE ONLY) Journeyman 02/ gOr
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