The URL can be used to link to this page

PP-287 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential 1 Owners Name Pot) / p 1 L- Owners Address 1 ` L Building Location `Sg- Date C/ New ❑ Renovation ❑ Replacement ❑ Plans Submitted El z C cn o z z w /, 0 - W H W E� U cs w x ,am , ,d w5 ±-= O W < WZ c zi=e = � — a2 a " HQx z - ic-. ¢ ww � w UdE" O zOO <4zXdOUH;i. E 4 e' o ¢ O Q U X c4 A Q x E-i ci) w 0 A d rsw gel O SUB-BSMT. J BASEMENT 1st FLOOR 2nd FLOOR 3rd FLOOR ' �1) 4th FLOOR 5th FLOOR 6th FLOOR 7th FLOOR • 8th FLOOR Installing Company Name 4 2 11 `�4-1i►u2 _ �2`7 Check One: Certificate Address .66 g / " - ❑ Corp. City State Zip Code I "I Partner Business Telephone: 7 -7 G d % t ❑ Firm/Co. Name of Licensed Plumber or Gasfitter �z--,---- e 5 i " l 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. I 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 I 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 the General Laws. B y r Type of License: e.'G_____ d Signature of Licensed Plumber Tit r.6 ❑ MASTER � 33 Gatv/Town 0 JOURNEYMAN License Number 0 F U W z Y un c. o a WW QwaA A 4 4 • i 4 0E. o a _ rM _i oA lib F., `A aA4 2 Z m J z Z R N Oa Q zO EW a © w 4., — M a. 0 O it a \z jF. Nil O ¢ \¢ 2 w ...,;PC�HU FT �, �" (i NN ,-45.0, �� ..lil�l�lllll! Vim:•,o ii U CAr W U , F