PP-211 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING V
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential
Owners Name Ake c -e 'r0 Owners Address
Building Location a I°''-4't\R. + ro S L ri , Date f I I le l q 4
New V Renovation n Replacement n Plans Submitted
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SUB-BSMT.
BASEMENT
1st FLOOR
2nd FLOOR 1 1
3rd FLOOR
4th FLOOR
5th FLOOR
6th FLOOR
7th FLOOR
8th FLOOR n pp�� --
Installing Company Name A•z. S • 1 'pf h 9) -1- It A,-) Check One: Certificate
Address i", O` Bo-( D-C`S E Corp.
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\ �/ City °r 9 v-r State /V A Zip Code Oa.-719 ❑ Partner
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1.." Business Telephone: q 9 0`� y�i ‘ Ft Firm/Co.
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Name of Licensed Plumber or Gasfitter "iArT h o it r. S c -Q•1
INSURANCE COVERAGE: Check 9ne:
I have a current liability insurance policy or its substantial equivalent. Yes o❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
A liability insurance policy✓ Other type of indemnity Bond
I 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:
Owner ❑ Agent ❑
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 Plu.�g Code and
Chapter 142 of the General Laws.
B y .v Type of License: ak142) '� 0
Signature of ;ens.. Plumbe
Title i ' q 4 i• ASTER usy/Town _Q�,vv ,..r 0 JOURNEYMAN License Number [Q R p 3 1
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