PP-751 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential ICI''
Owners Name R r z q f' S I c I g r r Owners Address
Building Location Lt .S t°tl J ci 4( R .�;Date 1 '! t
New Renovation ElReplacement 1—I Plans Submitted ❑ 1
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SUB-BSMT.
BASEMENT �,
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2nd FLOOR i 1 9
3rd FLOOR
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8th FLOOR
j . S V Installing Company Name • - , I/ !t 1- .7-{t-r, A ) Check One: Certificate
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•V '1 , Address n Corp.
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Zip Code/ 7J 9 ❑ Partner
Business Telephone: q Q e '4(4 P1 Firm/Co.
Name of Licensed Plumber or Gasfitter r I i) t.t r 5 'c 2. (I
INSURANCE COVERAGE: Check Ope:
I have a current liability insurance policy or its substantial equivalent. Yes Lio❑
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.
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 Plumbin Code and
Chapter 142 of theAimi s.
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i�.%�_/� , Type of License: \ �i� J
Tit f�Y, ,� Signature of Lic ed Plumber
,;(.-,� . wf,_;- / [3'MASTER
®y/T! sP:0 _ 1i' 0 JOURNEYMAN License Number 1 0 9 3 C(
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a. x PLUMBING PERMIT
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TOWN OF DARTMOUTH No. 75/
G - / o• 19:9Y
This Certifies, that A. "J' .5 4/21.
It
has permission to perform plumbing for V :a/ev S (AA !.
R. -n
in building a c) ( .o•o.4 Street
in accordance with the Massachusetts State Plumbing Code.
Fee o ep
Dartmouth Building t.
ffril
Plumbing Inspector