PP-48658 TOWN. OF DARTMOUTH
BUILDING RECEIPTS
COLLECTOR'S OFFICE
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Name;/ '%-� T -f-- �F / Property., f":/t �� Date: f 3 () /(t
j L„� J �V ` / � �1 ,l Owner: i
Job Location: �r �� �! /} r 0AR�00
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ll !'J CO ?plea - White Copy-Collectors Office
Plot: /' // Lot: ! / ! ,,rail. r3 u Yellow Copy-Customer's Receipt
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WI w 9 13 Green Copy-Building Department
Phone: �•9�P
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Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106
License&Permits-`4lumbing,&Gas 01000-44107 i ' e-J` / /• l 0ram_ - / ✓ l., ;
Other Department Revenue 01000-42420
This is not a Permit or License for Building,Plumbine or Gas Received By:
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) raven of Dartmouth
( /� ,Mass Da/�e -or 20 Permit#
Building Location 2 C G G`U,Sk.na(� 1/ Owner's Name --Tic eLk
Type of Occupancy g rs
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New 0 Renovation 0 Replacement 0 Plans Submitted: Yes 0 No 0
FIXTURES
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR I 1 f I . I I .
/ 3RD FLOOR
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4TH FLOOR
` / 5TH FLOOR
` �' 6TH FLOOR
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Installing Company Name iv `'�- 1"-c._ -LL, P (7 Check one: Certificate
Address 9 L( ( /(7l SS-c(/.S in.., c (7 et/ ❑ Corporation
Business Telephone .6-0S"2% (1'c( 7 0 Partnership
Name of Licensed Plumber � r /ii /vrn m/Com an
44 � P Y
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 12— 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 0
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 0 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 accurat o 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 nt provisi s e Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
By
Title Sign ur n d Plu er
City/Town Type of License: Master Journeyman
APPROVED (OFFICE USE ONLY) License Number 0
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