GP-478 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
DARTMOUTH, MASS. Type of Occupancy-Commercial n Residential
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Owners Name �44,‘D ti6141.14empePic, Owners Address O a .Su w t7,gwe 'Re_IN
Building Location ?2 Svw )$KE c Pc;ifi) V°'In il.Date 9/7 2— "
9 / _ New Renovation I 1 Replacement Plans Submitted El ,
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GBASEMENT ./C
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2nd FLOOR
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Installing Company Name . t.41 6--,YS Ce R P Check One: Certificate
Address * frf3 ok,,FGv Roil [ Corp.
City fl1 WtiAoc(s i ? State P' S/ Zip Code 0 17 3% ❑ Partner
Business Telephone: 7SY L/33P Firm/Co. _
Name of Licensed Plumber or Gasfitter 'Net is 4 "-c- r
INSURANCE COVERAGE: Check One:
I have a current liability insurance policy or its substantial equivalent. Yes IC 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
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.
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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 oft,- eneral Laws.
B y � 411° Type of License: Qt,. CO � \r
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Signature of Licensed Plumber or 4 fitter
Ti.trgA �.;a:iAllo ❑ MASTER ���
-41115?/Town � % _ ❑ JOURNEYMAN License Number
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