GP-55221 i
TOWNS OF DARTMOUTH
BUILDING RECEIPTS 55221
COLLECTOR'S OFFICE
Name: Property p J/rT a_,. Date: �:<i /i -'?
l / iit ,'t':? ii7 Owner: _ G (et 7 iC.IG }
Job Location:
White Copy-Collector's Office
Plot: / Lot: ) / G 7 - Yellow Copy-Customer's Receipt --
;id t� / Pink Copy-File Copy
Green Copy, Building Dep
Phone: ` h r-'.rr artment
Description General Ledger#'s TOV11 F DARTMOUTI I
CattECTOR S OFFICE,J Amo i `l-s'
License&Permits-Building 01000-44105 kC
NOV 2 0 21 OR / (ntk u
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical,' ` 01000-44106 M.A..-I I
License&Permits-Plumbing&Gas ) 01000-44107 0 1
Other Department Revenue(, 01000-42420 e
THIS IS NOT A PERMIT �
OR LICENSE FOR BUILDING, PLUMBING OR GAS Received B 1 :tom
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
=* tiWit"—r P4/27/1/0/I/ , Mass. Date //Ai) 49-20c9_
-1=.11= City, Town Permit #
, 1i_
Building Owner's
aM�i AT: Location S GZ49,c,92l1 L Name 774/A C7 ECG/
/r/, D,4/LrnnovG .-
Type of Occupancy: /1.OS
New n Renovation _ Replacement Et-
Plans Submitted Yes No
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V". Y 6 W J 4 ¢ 1- 1-Al > 10 m Z O Z W O N X
4 W > M W m Z 4 et 4 4 O O W — O W I-
iS X O 0 X u. m 3 O 0 J O X > O_6 1- 0
SUB—BSMT. _ ,
BASEMENT —
1ST FLOOR
2ND FLOOR _
3RD FLOOR
4TH FLOOR •
5TH FLOOR
6TH FLOOR _ _ — _ — _
1 7TH FLOOR
8TH FLOOR
_ — _ _ - _ — — - - — - — —
(Print or Type) Check One: Certificate
Installing Company Name /9/I?.O/eit,f (jd Corp.
Address ''/Z /an�Zt/i/kl st ❑ Partnership
'17i /14A2,l ❑ Firm/Company
Business Telephone _41,s - vv7`G Z 70 Name of Licensed Plumber or Gasfitter
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 Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner/Agent
I have a current liability insurance policy to include completed operations coverage. 0
By TYPE LICENSE:
Title gnature o ' n ed
❑ P ben , Plumber orGasfitter
City/Town Gasfitter s
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