PP-35310 TOWN OF DARTMOUT H~ 3 5 0
1WT {� .,_
I IOSS OL'LECTOR'S OFFICE
Name /;
Property / , Date �i, -
i Owner:
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Job Location , y,"
/ White Copy-Collectors Office
Plot: Lot: it: Yellow Copy-Customer's Receipt
✓ Pink Copy-File Copy
' ii �'' - -Ad Green Copy-Building Department
Phone: - - (._ - / v. 17-1:1;57i
Description General Ledger#'s Ref.#
License&Permits-Building 01000-44105 `i
License&Permits-Building Misc. 01000-44105 M Q, 13
License&Permits-Electrical 01000-44106
License&Permits-Plumbing.&Gas 01000-441077 t
Other Department Revenue 01000-42420
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This is not a Permit or License for Building.Plumbing or Gas Received By: �<
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS.S/ Type of�Occupancy-Commercial ❑ Residential Ig
Owners Name PQi /L`F 4 a- ,Q �L�9-L1vL Owners Address 'G al Lr
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Building Location % iiiii h(roi. Dr( U-C Date �0 D V'
New EL Renovation ❑ Replacement ❑ Plans Submitted ❑
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_SUB-BSMT. _
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BASEMENT _
1st FLOOR _
2nd FLOOR I I I
/I 3rd FLOOR
4th FLOOR
5th FLOOR _
2 \/ 6th FLOOR
i „...\ / 7th FLOOR
2 8th FLOOR
Installing Company Name ( I14Q(`d ?iaa win i k ) Check One: Certificate
Address /9(9 Tohal 15yer M�f ❑ Corp.
t City I - G State /P 2 lip Code 0 0 ?3 ( n Partner
Business Telephone: '7 6/— to S S -- -a �3 Irm/Co.
Name of Licensed Plumber or Gasfitter t tin G /�7(J,/5 Cl
INSURANCE COVERAGE: Check One:
I have a current liability insurance policy or its substantial equivalent. Yes El-t6 0
Ifyou have checked ye lease indicate the type coverage by chec ' ropriate box.
(A liability insurance policy Other type of indemnity Bond
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 0
tgna of fdiv is 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: _ �•��
'gnam of tensed Plumber
Title ❑ MASTER /3
City/Town ❑ JOURNEYMAN. Icense Number 491Z
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