GP-83115 TOWN OF DARTMOUTH - BUILDING DEPARTMEE RECEIPT 83115
PHONE 508.910.1820 FAX:15Q8.910.1838''\� "
Name: itgico.,„
, Property Owner: /l (iA v 77' Date: /"
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Job Location: --Map: Lot /
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Description General Ledger#'s Re.' Amount
Building &Building Misc. 0 1 000-44 1 05 ' 1 2 ' a
Electrical 01000-44106 ,^'
Plumbing & as 01000-44107 � , 7i �3- c
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Trench Safety 01000-44129
Other Department Revenue 01000-42420 _
14.1.---77
White-CollectoisOffice Yellow Copy-Custome2s Receipt Pink Copy-Building Department 1ZeeelVeg3
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
MA DATE!, % 7Y`r PERMIT#
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JOBSITE ADDRESS! ti a OWNER'S NAME Pir4
GOWNER ADDRESS I[j I gHi '� D -1TELII ' j1, (Q..Q f _ JFAXL., _1
P�RIDITR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL"(
CLEARLY NEW:J j RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO DI
APPLIANCES 1 FLOORS-. BSM ra
1 2 3 4 5 6 7 8 9 �11�0t 11 12 13 14
BOILER 1 d ' ` ll�L l I ,
Evacimammit L -raMI.MSW. ,M1 -1M- ,r
BOOSTER f' I I M I IM I .ISS
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DIRECT
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WEINISSIM
DRYERVENT HEATER rM i��
FIREPLACE
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11 .nain an ,I _ IFURNACE
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ewormass
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GENERATOR
al We:WS
LABORATORY INF ' i _. ,ram Ian '1___
COCKStaxmen
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ROOM I .W. 5
SPACE HEATER 55 Ia 1
UNVENTED ROOM HEATER a ift 1 1 -. r
WATER HEATER nI � II�i . j
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INSURANCE COVERAGE [[[ v
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES { ,NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I _
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Q BOND(PS
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 D AGENT 0
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 corn lance with all Perti en provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#I
MP 0 MGF 0JP 0 JGF 0LPGI ` CORPORATION:#r L PARTNERSHIPI J# .1 LLC Fp
COMPANY NAME: 'U�SSN 6f5.�_ �_ _,.,,1ADDRESSErail ,Jr�,__e .,. ---- ,_H.
CITY I svrL J rar STATE ZIP TJTEL[Q -(p9-a_t,d9T 1
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