PP-443 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial _ Residential C�,
Owners Name 1—0 C -S.i r`e r r-e ry Owners Address i e Tq r f O r'J �)i'•
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Building Location 0 i A PP( - P.a , Date /a 9/y 3 `
New Renovation ❑ Replacement n Plans Submitted n
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BASEMENT I 1 1 i i i i
P 1st FLOOR j i t
2nd FLOOR
3rd FLOOR
4th FLOOR
5th FLOOR
6th FLOOR
7th FLOOR .
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Installing Company Name A ���� ' P.� n 1. H 'i Ti n 9 Check One: Certificate
Address _ p O ° 8,X -).C,.,.j. n Corp.
City N' t'kg v (\ State A 4 Zip Code C>,a.1'1 Y E Partner
Business Telephone: qg 0Li n Firm/Co.
Name of Licensed Plumber or Gasfitter A r 7'h u r - \Sc''uZ.cj
INSURANCE COVERAGE: Check O
I have a current liability insurance policy or its substantial equivalent. Yes to ❑
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 in compliance with all pertinent provisions of the Massachusetts State Plumbi g Code and
Chapter 42 of Laws.
B y Type of License: t1.rik--t `.�
Tit ❑ MASTER Signature of Lie" ed ber
Cife0Town % 0 JOURNEYMAN License Number I 0 `f 3 9
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