GP-36568 TOWN OF §ARTMOUTH y" "
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BUILDING RECEIPTS
% •• 1-1 `'a COLLECTOR'S OFFICE
Name: - Property - .Date:.
L;:% .,,� Owner: '.rl ':_ . <• :C . --
Job Location: - -
(M' i )r` ‘C. ' 1-: C . `11 r .: ?? v'
White Copy-Collector's Office
Plot: _� Lot: ' - - Y. Copy-Customer's Receipt
; , ^''Pink Copy-File Copy
green Copy-Building Department
Phone: - -
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Description General Ledger#'s `\ Ref`#Y Amount
License&Permits-Building 01000-44105
License&Permits Building Misc. 01000-44105
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas_ 01000-44107 I C1 jet
Other Department Revenue 01000-42420 '\
This is not a Permit or License for Building,Plumbing or Gas Received By: 7
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFTTTING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential 1= 7_7(ag
Owners Name IkGi14K J&ilk e n S Owners Address A 04 k r 1 d3 8 Sr-
Building Location a OaR f id3e Oh Date /d -'2 1 -'d y
New E Renovation ❑ Replacement ❑ Plans Submitted ❑
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SUB-BSMT.
"' BASEMENT -
1st FLOOR
2nd FLOOR X
c 3rd FLOOR
4th FLOOR
e 2- 5th FLOOR .
6th FLOOR
4 ( LP 7th FLOOR
P8th FLOOR
7-
Installing Company Name,t70hr .cool/. ge.fierh eroPahe Check One: Certificate
\k7 (I b Address Pa' col, gs7 E' Corp.
City 7,0eStrov L State 4)7)61 • 7ip Code 0275 o ❑ Partner
Business Telephone: D 1 #16-,�// . 2 1 z_ ❑ Firm/Co.
Name of Licensed Plumber or Gasftter Xehh eX fR,t/IanSe5
INSURANCE COVERAGE: •'Cheek One.
I have a current liability insurance policy or its substantial equivalent. Yes 0 No❑
If you have checked yes,please indicate the type coverage by checking the appropnate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S LNSURANCE 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.
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Check One: i
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 Massachusetts State Plumbing Code.and
Chapter 142 of the General Laws. � y�J
B y Type of License: 7 <4; /lt1Yt an t4. l
Signature of Licensed Plumber or Gastitter
Title 0 MASTER Cin'Town = JOURNEYMAN License Numbefi t V
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