PP-161 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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A� � TOWN OF DARTMOUTH Date_ C 7 19 7/
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L4T z Permit # `��
=� Building // ✓ Owner ' s / ,( ///�
AT: Location ,/ 12S. Name 7 cc c-4- 6 D_ rf—
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PDAR / 71-no t/7Jjr Type of Occupancy: '
New ❑ Renovation ❑ Replacement 0
Plans
FIXTURES
Submitted : Yes ElNo ❑z_
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SUB-BSMT.
BASEMENT I. ( I 1.
1ST FLOOR i / / L - ;
2ND FLOOR - _
3RD FLOOR
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4TH FLOOR
5TH FLOOR
6TH FLOOR .
/ ' 7TH FLOOR
Irk 8TH FLOOR
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Installing Company Name e_(i/K, G(/ Check One: Certificate
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Address /a/ C'ov-r S /
® Partnership
5CtJ4nJ 5-e 14- — 0 Firm/Company
Business Telephone (7 6. 3 7 d 5 Name of Licensed Plumber
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I hereby certify that ail of the detail 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.
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.C
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By /�_Lt. i _ S s t _�
Titl `e y, //�%?O� —_ Sig atu.re of Licensed Plumber
City/Town: Type of Plumbing License
APPROVED (OFFICE USE ONLY) License Number ❑ Master [}J urneyman
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