PP-723 VOID MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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DARTMOUTH, MASS. Type of Occupancy-Commercial 1-1 Residential _ .
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Owners Name/1?f1a/l€411 U/hl6 e C_. Owners Address Stu C- /5—
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Building Location I C SUn/ e 7t/C" cd Date �� 6179 ' i
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4✓ New Tr Renovation ❑ Replacement ❑ Plans Submitted n
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BASEMENT I,
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3rd FLOOR
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v) Installing Company Name,D007 i•S Pi A) /f/'g /4'tCheck One: Certificate
4 ✓ Address iq 0/i7'L'(.. hid LT Corp.
/ City pt./WOO/4i State fl74 Zip Code 063g6 0 n Partner
Business Telephone:rag-- 7 ht 7- 0 59/ ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter 00d /✓a-S g , /1414/Y4 r/1r,tee O7 C_
INSURANCE COVERAGE: Che Sne:
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.
A liability insurance policy"Other type of indemnity Bond
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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: r V
Owner D Agent D
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 Massachusetts/' State Plumbin ode d
Chapter 142 of the General Laws. (\/
B y Type of License: si //v*� /F
� � Sign re of Licensed Plumber
Title Ik STER
City/Town ❑ JOURNEYMAN License Number /670- Y
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