PP-142 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, 'JMASS. Type of Occupancy-Commercial ❑ /JResidential R
Owners Name�1*0:-' c?V/t4'S Owners Address /100'�r,Lc/96/F
Building Location ‘,2 ( /l.P')6c J/C �2 Cr' Date ///�
New Renovation Replacement ❑ Plans Submitted 1-7---
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P SUB-BSMT.
BASEMENT / /
1st FLOOR / / / I
2nd FLOOR 2. 2 2 .
3rd FLOOR
4th FLOOR
5th FLOOR
1 te 6th FLOOR
(I 7th FLOOR
I 8th FLOOR
,'-j Installing Company Name gC/.S�ier77A04/l./�. 'e74 Check One: Certificate
r. Address /67 es:tre G=-*dee) ❑./Corp.
City I1e.75,71",✓ State �/1 Zip Code ❑ Partner
Business Telephone: /g3c %,>>/,,t ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter /ff/./G a�FG!(.)
INSURANCE COVERAGE: Chec One:
I have a current liability insurance policy or its substantial equivalent. Yes El No 0
If you have checked yes,please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
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,as tom�� si tore on this permit application waives this requirement.
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-o/ Check One:
/( �r��` /� Owner ❑ Agen[ ❑
Signature of Owner's gent
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 Plumbing Code and
Chapter 142 of the General Laws. f//��
B y Type of License: / �iL�%r'xp (��/�� '
Signature o Le/ LidClt>redPlumber
Title ❑ MASTER
City/Town JOURNEYMAN License Number /2e//
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