PP-249 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential ❑
Owners Name �. G-cxi-AUtv\ Owners Address t C0k4^-$
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Building Location <'?i Colk. r 1 O C I is , AA* Date t y
New Renovation n Replacement Plans Submitted E
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BASEMENT $
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2nd FLOOR
3rd FLOOR
4th FLOOR
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Installing Company Name L2C f I Q C' �d Rlelk Check One: Certificate
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Address /S 7 Cr:.4.j J ❑ Corp.
City ' ''`G<'R'® �t(0 State Zip Code f -?3 6 ❑ Partner
„., Business Telephone: Firm/Co.
Name of Licensed Plumber or Gasfitter_ I s' A c, C Cc Q
INSURANCE COVERAGE: ese:
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 propn box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER:I ant 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 Masschusetts State P bing Code and
Chapter 142 of the General Laws. r
B y Type of License:
Title MASTER Signature of icensed Plumber
City/Town 0 JOURNEYMAN License Number /.36
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