GP-48659 _ <_
TOWN OF DARTMOUTH
48659
BUILDING RECEIPT$
COLLECTOR'S OFFICE
L�.
Name V) t.ii� �/ `,
��"l L.� / f } j Proper / / 1// )/ / /
L f! Owner'f J O'E�v[!' Date / 3J 2'� /
Job Location: / ! f
- L=% / -7,---c i 4-'"'r- �-- Z R TOWN OF DARTMOUTH
Plot: ./ ,!,-• / _ 7 9COLLECTOR'SOFFICE White C Collector'sOffice
' Lot: r 'r;37 - Yellow Copy-Customer's Receipt
i.. i Alit i V LiAi I Pink Copy-File Copy
Phone: r3
r n r 4 7 73 9 NIA J A Green Copy-Building Department
Description General Ledger#'s Ref,ft/w
' Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106
License&Permits-Plumbing ,Ga_s�� " 01000-44107 /t C�. `
& /_ )
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 GASFITTING
(Print or Type) lawn of Dartmouth
, Mass Date Y "e6 —0 7 20 Perrmit#
Building Location a C. Cr n( a QLtrc �-*------ Owner's Name rrl S AC _&Q
Type of Occupancy t5
New V Renovation 0 Replacement 0 Plans Submitted: Yes 0 No 0
s oG
A m C Co 0 D m - 73M 0 m O O m
I l - D m O 4� Z A Z 93 A m y N O A C r0 ~ A `,A tY !1 _I , apt
z x 0 rt O Z s < Z O p 2 O m i m m
7 t ai m �n �n o m m -' W 8 n m O s T m '�T
G) m O A m O O Z z m W Coy
e m co ZI n 2 N H y fn
co N co
N m N Z kk xi
SUB-BSMr.
BASEMENT
1ST FLOOR
2ND FLOOR ( I I
3RD FLOOR
4TH FLOOR
5TH FLOOR i
6TH FLOOR
U '. 7TH FLOOR
8TH FLOOR �
Installing Company Name *AC/ ( v GL' I i_ iF Check one: Certificate
Address 9s'( 62,,5 5-C7( /44-(! 5 £D
0 Corporation
Business Telephone 00329/gv ❑ Parthe hip
Name of Licensed Plumber or Gas Fitter_ AV-IL�tJifT,
irm/Company
INSURANCE C
I have a curr liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No❑
If you have checked y ,please indicate the type of coverage by checking the appropriate box. •
'.
A liability Insurance policy 0 Other type of indemnity 0 Bond El
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 or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accu to the best of my knowledge and that all plumbing
or gasfitting work and installations performed under the permit issued for this application will be in complia with all inept visions of the Massachusetts State Gas
Code and Chapter 142 of the General Laws. ///�
By
Title Sig to e of Li nsed Plumber
City/Town Type of License: Plumber Gasfitter ❑
APPROVED (OFFICE USE ONLY)
as�r/Y Journey
License Number i
Map Lot a - 7
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