PP-84240 "�. TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 84240
p Nog. 5Q8.910.1820 FAX*508.9%1838
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Name::L:U �r -w ! y'UDC d Property Owner: / / ' Date //�
Job Location: /�� LV (.4-/ t'jF Map: (fib Lot'�—1/ C
Description General Ledger#'s f Refs # ' ct m Aount
DA Y6
Building & Building Misc. of �4 Y a.r 105
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Electrtc 1 ti� 01000-44 06
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Tl bing�& Gas =` 01000-4411;7 AIP 7 /7t 1 ;- ))
TrencSafety 0W000,O14 29
Other Department Revenue ii "ii';ti--42420
White-Collectors Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received B
THIS IS NOT A PERMITILICENSE FOR BUILDING ELECTRICAL PLUMBING OR GAS
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
mtlioir I�HU CITY/TOWN . `ClVl S,_k MA DATE 2 -- \---1 PERMIT#
JOBSITE ADDRESS \C) l ArtC(271C'r i l A )\RI � OWNER'S NAME llCiOd\ 3�Y.a t^ `i'�(inS��y )���f�
P OWNER ADDRESS %CS TEL6d8- o17c6 FAX X
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL L
PRINT /
CLEARLY NEW:Id RENOVATION:0 REPLACEMENT: ❑ PLANS SUBMITTED: YES 0 NO Lam"
FIXTURES 7 FLOOR—r BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URIISAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER V.�iix'n"�G oSrv'�`il`J I /
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INSURANCE COVERAGE: . �/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES b�' NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1:11/ 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement-
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this 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 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n„_ L'
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PLUMBER'S NAME
t an u-t g O LICENSE# SIGNATURE
MP,, -i JP CORPORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME ,g1lt.fl F.--- thtaefiss ADDRESS '0\a \Dt% n9� ScePn
CITY SI LYC.ttd'Ihr r 1 STATE Ol ZIP Oa a at TEL cog-- Fr&b-4eYj
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