PP-64099 TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 6 4 0 9 9
t PH0NE:r508-9104820 FAX: 508-910-1838
No,
7
Name:ti. I` /t i nit.(C Property Owner 6aitr L{%�ic.e Date:8�22-th
Job Location: 94 1 %1/4 (i / Map: 26 Lot: `-2-
Description General Ledger#'s Ref. # Amount
Building & Building Misc. 01000-44105
Elpetrical 01000-44106
Plumbing Gas 01000-44107 12/ j # 11
i(Eren afety 01000-44129 sr
Other Department Revenue 01000-42420 (V .
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White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department ReceivedBy i" -ti ; j?,,,-,, f
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THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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=iil70o City/Town: Det (�1_,Li ') , MA. Date: Permit# 69a 9 9
Building Location: 1/6 4 /e/C- J Je Owners Name: (016/74 pJ02>
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional ❑ Residential0
New:n Alteration: n Renovation: Ialf Replacement: n Plans Submitted: Yes E No n
FIXTURES
DEDICATED
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BASEMENT
1ST FLOOR / /
2ND FLOOR / 2.,.. /
3RD FLOOR
4"FLOOR
5"FLOOR
6TH FLOOR
7"FLOOR
8"FLOOR
�^%� Check One Only Certificate#
Installing Company Name: `.J� 17/CS
S�- �.i/)� ❑Corporation
Address: / V{1` f✓�City/Town:�,412/I//&1 State:
/1p C ❑ Partnership
Business Tel: 5-0 S5 0 b DO Fax: ��
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Name of Licensed Plumber: C �JOS'1 Pe- I ) ( `"
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 below.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAI R: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Law , and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's 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 1 the Gen ral Laws.
By Type of License:
Title ❑ Plumber Signat f Ltc d Plumber
City/Town ill Master j Y
APPROVED(OFFICE USE ONLY) ❑Journeyman L tense
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