GP-17238 TOWN OF DARTMOUTH 17238
BUILDING RECEIPTS
COLLECTOf'S OFFICE
Name: t 1 ' , RAC ` r (Property ., ,. t' } i t-... Date: . `r /l' (3
ii lL-k J _ A_ r CC ji V?„ ,Owner: _ ! /- t1 -
Job Location: /�/-� !
White Copy-Collector's Office
Plot: /7(3 Lot:. ) - /?f"`] Yellow Copy-Customer's Receipt.
! Pink Copy-File Copy
Green Copy-Building Department
Phone: TOWN Of DARTMOUTH / '',� _.
COLLECTOR'S OFFICE l
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105 SEP 18 ZOO
License&Permits-Building Misc. 01000-44105
License&Permits Electrical 01000-44106 C S CO U /
License&Permits-Plumbing,CGas 01000-44107
Other Department Revenue 01000-42420
F
This is not a Permit or License for Building.Plumbing or Gas Received By:
rSSSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
• .,-`DAkTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential
Owners Name &\tit %t'fl 1/2 Owners Address 9 — / Oro
Bu' ding Location % 3 . ' *tC4 Ni . Date
New VA Renovation ❑ Replacement ❑ Plans Submitted E
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SUB-BSMT.
: G BASEMENT
1st FLOOR x X
2nd FLOOR
3rd FLOOR
4th FLOOR
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Sth FLOOR
6th FLOOR
7th FLOOR
8th FLOOR
Installing Company Name j V...?<- s\efkk‘- Check One: Certificate
Address tc , ® Corp.
City t5��A State \\* 7ip Code ❑ Partner
Business Telephone: �O`9. ' "4 v•N ll ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter'itO f M ' F6 A i da
INSURANCE COVERAGE: '•Check One:
I have a current liability insurance policy or its substantial equivalent. Yes 0 No 0
If you have checked yes,please indicate the type 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 Ott:
Owner 0 Agent 0
Signature of 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 of the bus mg Code and
Chapter 142 of the General Laws. •
B y Type of License: CPtie_d
a re of Licensed lumber or Gasfitter
Title ❑ MASTER ) �
City/Town 0 JOURNEYMAN License Number Lip
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