GP-31035 TOWN OF DARTMOUTH 31035
BUILDING RECEIPTS
P = -Q, gA RF r re _; COLLECTORS OFFICE
Name: ,--' ., Property 1 1 - Date:: '' /
;/ .f of f 1 i_ ;.ter n;; -- -�-c._Y/J f LJ f r' i is f
t-K• Owner:
Job Location: ! / _ .'
--- White Copy-Collector's Office
Plot: / 7 - Lot: .r el'' , Yellow Copy-Customers Receipt
Z(•L t g Pink Copy-File Copy
Green Copy-Building Department
Phone: - - -
Description General Ledger#'s col, Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105 ,
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License&Permits-Electrical 01000-44106 /
License&Permits-Plumm bg Qas r% 01000-44107 ``�i t' , -- t t c---C}
Other Department Revenue 01000-42420 % f _
This is not a Permit or License for Building,Plumbing or Gas Received By:
CA-___.
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DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential L4k
,/` Owners Name &( 14v4, & Owners Address a Cy e/416>voia�
Building Location Date /6— 2-CC?
New 2 Renovation ❑ RepIacement ❑ Plans Submitted 0
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„GSUB-BSMT.
BASEMENT
1st FLOOR s
2nd FLOOR
3rd FLOOR
6,;/ 4th FLOOR
5th FLOOR
6th FLOOR
1 7th FLOOR
8th FLOOR
Installing Company/Name S>4/t t /2�� Check One: Certificate
Address /7 9. 61 ,,rest/' Corp.
CityLQs✓'er yr C( State Aid Zip Code Os"7 0 Partner
Business Telephone: 7aO "9'%l/9e) 0 Firm/Co.
Name of Licensed Plumber or Gasfitter ,dCc 2(//l'-P ,
INSURANCE COVERAGE: .'h� nn/_O
I have a current liability insurance policy or its substantial equivalent. Yes IJ'No 0
If you have checked ya.please indicate the type coverage by checking the appmptiate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER:I am await 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 Plumbing Code and
Chapter 142 of the General Laws.
B y Type of License:
ignature of Lice umber or Gasfitter
Title ❑ MASTER
City%Town "7- FOURNEYIIAN License Number 6a'24%3
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