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GP-46693 TOWN OF DARTMOUTH 46693 BUILDING RECEIPTS COLLECTOR'S OFFICE Property f�, /-/ Date: �rG '` j"�'`%+' ' i�(• ,'.�• .Owner: .f �� ��" •`G� Job Location: �� /ii `� TOWNOrDARTMOUTH White Copy-Collector'sOffice Plot: /` Lot: t�'� COLLFCTOR'SnrrICE Yellow Copy-Customer's Receipt E t! / f� 21��i ��(�� Pink Copy-File Copy Green Copy-Building Department Phone: - isms No TAT - Est f MA.313 Description General Ledger#'s Ref.# Amount License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 License Sr Permits-Electrical _-- 01000-44106 License&Permits-Plumbing S Gas 1 01000-44107 inia _ Af Other Department Revenue - i 01000-42420 fr i - This is not a Permit or License for Building,Plumbing or Gas Received By: ^7L-L < C MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) ?own of Dartmouth /� 12l4I- 29; , Mass Date // o/ 20 0/ Permit# `" /3 / Building Location � 2 E.9 Aced f&V Owner's Name/AI/C1.9 e/ �QC/Vie.1.2 Type of Occupancy /efIa4..?c e New Renovation 0 Replacement 0 Plans Submitted: Yes 0 No Lt- N S o z m m }� "'y Z D ai pOp < 0 m rm'lm I^: I ci fy* O G2 Z C ti m O O D y OT A < Or -1 POe r t^ \C m AG) z fmn sm < Z O O O S 2N m �y2 _, mZ - mD D m ;mU 9 z V 0 F, rn p m�� yC y Z to N O m mti n CCS mN O A G) m co A m O O z z m A -D_i fff �� m N y ,,1 O Z N ti N C�v�,� m O "'ram N to N N 0) ti z SUB-BSMr. BASEMENT 1ST FLOOR `b 2ND FLOOR 2 3RD FLOOR 4TH FLOOR l6, 5TH FLOOR � I J c.. • j 6TH FLOOR " ,[4 / 7TH FLOOR r 8T1-I FLOOR Installing Company Name U 5@icyh ic'oPQhr.. Check one: Certificate Address 0- 110>0 RS7 �� fit?9 b L�J Corporation s`dye 7'oh� /f1r . Business Telephone ..,F 656 - 2.>?32— 0 Partnership Name of Licensed Plumber or Gas Fitter j , fFP ?c CS 0 Firm/Company -71 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yeb ❑ No❑ If you have checked m,please indicate the type of coverage by checking the appropriate box. A liability Insurance policy❑ Other type of indemnity❑ Bond 0 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 or gasfitting work and installations performed under the permit issued for this application will be in compliance with all pertinent provisi s of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By .nv ,M.J Title Signature of icensed Plumber City/Town Type of License: Plumber ❑ Gasfitter trer APPROVED (OFFICE USE ONLY) aster ❑ Journeyman 0 License Number Ma }/ Lot c - i a 0 \ E 2 , \ \ a a ƒ ) ] ) d 2 \ ƒ - a .. / . § [ [ ` E. . k { E. / \ \ 0 . ti (IQ CIF\ : ?, » / E It % . % E~ / 1104-R O O 0 § � . b _ © / / / N ) \ 2 ƒ A 2 MD O §Sk \ / \ � CI ) E E E ro / N r r r m � ■ \ \ \ \ ) 7 ( { \ \ e § � f @ _ $ ) e ) aPcm ri § / / § % k7b nd - 0 \ et e� � r CA \r $ Z _ / i 2 p t, - .. ] El1'1\73 a" E 2 § § 5 • r