PP-62481 • .��., TOWN OF DARTMOUTH
r' x BUILDING RECEIPTS ;
_s s fi EH,ONE& 508-910.1820 FAX 508-910.1838 -.
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Name: - ,:rropeny Date:
: _T s Owner: try-
Job Location: White Copy-Collector's Office
J Yellow Copy-Customer's Receipt
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Pink Co File
Copy' Copy
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f Green Copy-Building Department
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Phone: i� 9Description General Ledger#'s \\tt��\J ef. # Amount
License &Permits - Building 01000-44105
License & Permits - Building Misc. 01000-42n05 y
License & Permits - Electrical 01000-44106
License & Permits -Plumbing & Gas 01000-44107 f'
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License &Permits - Trench Safety 01000-44129
Other Department Revenue 01000-42420
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLUMBING OR GAS
Received By:-'
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) II TO'W92 of Dartmouth.
r''}MoUg-L , Mass Date Vi 41/46// 20 � /� Permit# 6 2
Building Location 3 T8/ueberry /e3,.e Owners Name (is//er' a...6n/
Type of Occupancy ric%n /is
New 0 Renovation it, Replacement 0 Plans Submitted: Yes ❑ No0
FIXTURES
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SUB-BSMT.
BASEMENT
1ST FLOOR 1 '. I - I I . '_
2ND FLOOR
3RD/ 4TH FLOOR
7//// 4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR "ltirn L /
Ies at Iling,�;ompansy�lName aim ►J i fr'el 7 �esf�/ry Check one: Certificate
Address r•o V • �O K I 0 3
❑ Corporation
1-54II2—Sirt4veo% An 0
Business Telephone (so3) 95?'/6'- ElPartnership
Name of Licensed Plumber CVt o ci im, -BrO ldn ❑ Firm/Company
INSURANCE COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No
If you have checked y, lease indicate the type of coverage by checking the appropriate box.
A liability Insurance policy 0 Other type of indemnity 0 Bond ❑
OWNER'S INSURA Cc am aware the I' ensee d spot have the insurance coverage required by Chapter of the Mass.General
Laws awl m rm li on w fives requirement. Checkk One:
One:
Owner Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application an ue and.ccurate 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 wi ._all C. Then �.visionsshe Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
By
Title Sign. r re of Licensed Plumber
City/Town Type of License: Master 1:1
�+��Journeyma jr
APPROVED (OFFICE USE ONLY) License Number S---0053
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