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PP-463 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential Owners Name C/ / rid--10 l(./ Owners Address '&7/4pi L5 1 m �:O �7Vvi) MIS. Building Location \Y(.4 /0 C ?- 0 % Date V--/ 9 S D New [LV--- Renovation ❑ Replacement I I q0) laps Submitted ❑ z z z x ¢ w •.,=- o - es H wF U a4 v ¢ �, U Z p G4 ¢ & ¢ w Z A ¢ n A aa g O w '-' k - � ¢ xa __.— _-_--:--j4,� x3ozz3 oE" zzw xw wo �' I x .¢a Clrwn L1 A 1 3 x H v w a 5 A ¢ 3 x as o SUB-BSMT. BASEMENT �- 1st FLOOR 2nd FLOOR '— ti 3rd FLOOR 4th FLOOR , E 5th FLOOR 6th FLOOR 7th FLOOR 8th FLOOR �p Installing Company Name 14, V/4-(0c)& J . Check One: Certificate Address 3 f I J?) ❑ Corp. City pi...../04.t?v� r State 4, Zip Code e ,3(O ❑ Partner Business Telephone: 26 9.6 0 7 l.i— Firm/Co. Name of Licensed Plumber or Gasfitter / L-, 3T--(aif}C- INSURANCE COVERAGE: Che4 Ope I have a current liability insurance policy or its substantial equivalent. Yes o E If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond s 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. , d 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 lumbing Code and Chapter 142 of the CGeperal Laws. all--4-t. By ; c,.. f����B y jType of License: ( �ASTER Signature o cens Plumber Title Q /Town .r cc. ❑ JOURNEYMAN License Number l5 t7Z-©» C r r f C I. k li C. I II II I_ I I I I I __ II I I A_, l r / ar,.°F .,1n A° -o ;y `0p, � c z HNlli • 1, c r o4. ro 8inn‘ � n � �� z' Q .• `��a y 3 ++ d Co�' I c �� z r C ,p .:..,.---i-'-,,,_-_=--_,.-„:::' C � z N. b ?V � i r 1 trI x y y. IC/ 1� co) 0 A7• V i ..7-- • ,- i ,0 k `•ll �„ Cn 0 z