PP-174 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential I `t'� _
Owners Name (/i�V_ 1. /71 // Owners Address
Building Location -.'//7 C p&l6o..S 2-- /9 i v C Date 4— &—
New [ Renovation I i Replacement ❑ Plans Submitted ❑
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BASEMENT / / ) C / )
1st FLOOR I / I I /
2nd FLOOR
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Installing Company Name rD V r F 7" Uv I)Nt11. S (717— Check One: Certificate
Address U B;-/4 g•-• Cl i T F g P n Corp.
City 1 /ia `l (!cNState 7 / Zip Code 2-7 7( f "r Partner
Business Telephone: 7"7 76 Q y r n Firm/Co.
Name of Licensed Plumber or Gasfitter & _ i_4 1
INSURANCE COVERAGE: Check One:
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
4 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 Plumbing Code and
Chapter 142 of eneral Laws.
B y `-'4 Type of License:
Signature of Licensed Plu er
Title ❑ MASTER
esy/'pown ❑ JOURNEYMAN License Number
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