PP-62275 s _ TOWN OF� ; RTMOUTH
BUIL['ING-RECEIPTS ;,
PHONE,,,,
508.91Q�1820 FAX 5089101838 NO Dix iss: 75
Name. / (!1 �/ rropeny ' to f Date: f, `
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Job Location: 'i / • White Copy-Collector's Office
Yellow Copy-Customer's Receipt
Pink Copy-File Copy.
Map. / Lot: .'/ /2 Green Copy-Building Department
! I C t n '-' I ) '-'
Phone:
Description General Ledger#'s Ref. # Amount
License & Permits - Building 01000-44105
License &Permits - Building Misc. 01000-44105
License & Permits - Electrical,_-, 01000-44106
License &Permits - Plupbing& Gas 01000-44107 /,,, %,r; ,' 2 (."t.,i j I
License &Permits - Trenelr Safety 01000-44129
Other Department Revenue 01000-42420
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLUMBING OR GAS
Received By: •
' �`
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) 'Down of Dartmouth
vri-f VlOvf li , Mass Date Jan /71i20 //./ Permit# 2 2- -2 S
Building Location 7 tir2.m C4n6- Owner's Name 72ii Covr7
\ Type of Occupancy '11 _5'r:L4 7A/
Newer Renovation 0 Replacement 0 Plans Submitted: Yes ❑ No 0
/��\ FIXTURES
cg x y O m 73 CO Z D 0 -j�cy�$
A�,/� -➢I Cl 5 T- O & O C Z .. y § ➢ Y O n 2 TS
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Py. • '�, r' Z m N > m F � ti N a D 'O C
m .0 fn Z U' C) D (/� N Z N Z Z Z Z .0 A
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SUB-BSMT.
' BASEMENT n
1ST FLOOR r
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
it X 6TH FLOOR
'`/ 7TH FLOOR
' 8TH FLOOR/�
Installing Company Name ( N(I IC Yiumb'll-b {4P�eT)c1 Check one: .f Certificate
Address 10 iNi& 1J �} 1 41-1
0 CorporatiortRZ 11.,
Business Telephone ")D' /n3)7- ts- -9- 0 Partnership`-`''j
Name of Licensed Plumber VVW?-1St pAt}2- hEi7it 0 Firm/Company
INSURANCE COVERAGE:
I have a current 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 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❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above applicatio are t e and ac rate 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 ' all rtin r isions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
By %
Si Lure of L ensed Plumber
Title \—
Cityffown Type of License: Mast r 0 Journeyman 0
APPROVED (OFFICE USE ONLY) License Number
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