GP-94900 TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT
PHONE: 508-910-1820 FAX: 508-910-1838
V :
1 '
Name: / /; 'J„ _Property Owner:', r t I. F,`133 r t it L ti ;Date ,•
Ma ��,
`-"VA' �
, ot: ��
Description General Ledger#'s 2 Ref. #v g Amount
Building & Building Misc. 01000-44105
Electrical 01000-44106 ``ACTOR
Plumbing &Gas 01000-44107 f;f'
Trench Safety 01000-44129
Other Depat`finent Revenue 01000-42420
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By , 7, '
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
rCITY: �1J2TMoovr1 MA. DATE:2-S- 002.0 PERMIT#qW).610
JOBSITE ADDRESS: 5 Kroou_ WOO De . OWNER'S NAME:Oos3 3215So,J
GOWNER ADDRESS: .SAr-c TEL:774-644'0571 FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
PR NT
CLEARLY i NEW: RENOVATiON: ❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
APPLI'tt oEci PInoR_ I Esmt j 1 I _ 3 4 I . _ 7 1 .o I 2f 10 11
BOILER
BOOSTER I
COOK STOVE
DIRECT VENT HEATER
DRYER I I I
FIREPLACE
FRYOLATOR
FURNACE 1
GENERATOR 2d ' ) N I
GRILLE I^ED HEA-T Cn f I I .�LA5ODATORi COCK /varFUr;irLJiT C' Lf
I .I
OvEN •f '
POOL HEATER
fI I f
ROOM/SPACEHEATER f f I f I f
ROOF TOP UNIT f
TEST f I I I f f
UNIT HEATER /I
UNVENTED ROOM HEATER
WATER HEATER I I I J I J f
Oo�a rt
..+ .r000 Uc� b t I
f I
f 1 I� � I1
f i I I f I 3
" INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES YI NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
(ABILITY INSURANCE POLICY 1 OTHER TYPE INDEMNITY ❑ BOND E
OWNER'S INSURANCEWAIVER:'I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Generab`awa,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 142 of the General Laws. /( t, .
PLUMBER/GASFITTERM NAME: i .2K CRaee,tu.a LICENSE#'O 2 SIGNATURE
ER `—
COMPANY NAME: Sate]ZS PP e-,p ta,-5 G : ADDRESS: -tvc CaAn ogad_ .
CITY: 1 I rc 2 to„-) STATE: R.T. ZIP: O Z&28 FAX:
TEL:4,24- l 5 CELL: EMAIL:
MASTER 0 JOURNEYMAN 0 LP INSTALLER CORPORATION❑# PARTNERSHIP 0# LLC❑#
1
y �
z
z
I el�_ I I I i
I I 1 I i
1 1 I I I I
2; 1 1 1 1 1 1 I I I I I I I I i 1 1 1 i I
i 1 1 ' 1 1 I 1 I 1 I
-,1 �1 l l l 1 1 I 1 1 1 I i i 1 1 1 i 1 ' 1 ' I I
1 I I I i i i 1 I I 1 I 1 1 I I I I 1 1
i I 'i 1 I i 1 I i i i 1 1 'i 1 i I i
I I III
1 0 ' i i 1 i 1 I 1 1 I 1
I c'i- Pil ctji .c..-11 I .
o o
a F- 5 a
H
p c `w .✓
rgN o-^, W
o
U o
'4 y I� 111 �{
ti U `vIfIVI
y J
Ft a 4.
y al
H u. i
4
F
0
A'1
O \
F
U
lie/ i
Lot
0 - - i
All
•
•