PP-59325 / . TH.
TOWN OF DARTMOUTH
�o � BUILDING 14EGEIPTS
x Li a t 0tE 508-910.1820 FAX: 508-910-1838 • 5 9 3 2 5
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Name: I f/ t� { * to ert / .7 / Date: /
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Job Location: - i / f� / ' + J rf; % _ '' / White Copy-Collector's Office
• / t/ f f / 6 t (_j\-�..A...-A, � Yellow Copy-Customer's Receipt
III. 14. iv
"./ Pink Copy-File Copy
Map: / Lot: / 7 '+l
1 Green Copy-Building Department
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Phone:
Description General Ledger#'s Ref. # Amount
License & Permits -Building 01000-44105 °
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License & Permits - Building Misc. 01000-44105 ' GO)-10,10 14i
License & Permits - ElectricraI 01000-44106 ( (
License & Permits - PlUtnlh ng &.OTas 01000-44107 fi e4` /i;` f ('1)
License &Permits - Trench Safety 01000-44129 P J,,Cte
Other Department Revenue 01000-42420 "
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLUMBING OR GAS
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Received By: L; t).-
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' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) `lawn of Dartmouth
, Mass Date ��>0 20 Permit# /����
Building Location l�4 LC,,,-,c /r� J'Jtrfte Owner's Name C ya''
elt
Type of Occupancy /4si2.-6-07.-_/
New Renovation ❑ Replacement 0 Plans Submitted: Yes 0 No 0
FIXTURES
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SUB-BSMT.
. i:J BASEMENT - I
���1 1 I I I,^ 1ST FLOOR
e..,, 2ND FLOOR 2 Li
t,1 3RD FLOOR
ti 4TH FLOOR - - • -
/ 5TH FLOOR
7, 6TH FLOOR
7TH FLOOR
( �1 i 8TH FLOOR
✓Installing Company Name Sa rs /v-+6 7 { 4471.-y 4ge' Check one: Certificate
Address a�.t. ' U
0 Corporation
/9roew / /77'a- /l 76.2
Business Telephone 77 V 936 /.7c ID Partnership
Name of Licensed Plumber s.,.- ---n/.,;-h..-fir 0 Firm/Company
INSURANCE COVERAGE:
I have a curr nt liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box.
A liability Insurance policy 0 Other type of indemnity 0 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❑ 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 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 the Massachusetts lumbing Code and
Chapter 142 of the General Laws.
By
Signature of License lumber
Title
City/Town Type of License: Maste Journeyman 0
. APPROVED (OFFICE USE ONLY) License Number 732,7
Map 6 Lot - 430
Pic CD
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