GP-39246r- , , TOWN OF DARTMOUTH s;
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name ! F Property Date:,, d}
i c = 1" [ 1(:..} 1 j` Owner: = !//t 7` A% d s i�,r / ,)
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Job Location: 1
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pnn fi-"-------White CopyCollector's Office
TOWN OF OAOiT ,H -
Plot: '- Lot: i COLLECTORS OFFICE Yellow Copy-Customer's Receipt
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green Copy-Building Department
Phone: t 1 =i` lrt ,' {._ MAY 9 005, .()
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Description , 4TXISSU' & 's L Amount
License&Permits Building 01000-44105
License&Permits-Building Misc. 01000 44105
License&Permits-Electrical 01000-44106
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License&Permits-Plumbinj&Gas 01000-44107 I _ �
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`ther Department Revenue -- 01000-42420
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�s not a Permit or License for Building,Plumbing or Gas Received By: -",.r r- `` .r, x=..L-4 --r----
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASi iri'1NG
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential la"
Owners Name 7107 e,VOS
t Owners Address V 1iu?e/h > L/
Building Location Q mE r)e,V&S Z f1 Date -6, 7-6
New 2/ Renovation ❑ Replacement ❑ Plans Submitted ❑
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G SUB-BSMT.
BASEMENT
1st FLOOR
2nd FLOOR
3rd FLOOR
�r 4th FLOOR
� 5th FLOOR .
I(V 6th FLOOR
3%/ 7th FLOOR .
f V 6 8th FLOOR
Installing Company Name
Propane Gas Inc. Check One: Certificate
Address 875 State Rd. Unit #1 ❑ Corp.
. City 1 WesStno_rt.MA 02790 0 Partner
Business 'Telephone: ', 5C' d 7/1 /� 7 q 0 Firm/Co.
Name of Licensed Plumber or Gasfitter kO 7— R ,e&3
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INSURANCE COVERAGE: 'thecl ne:
I have a current liability insurance policy or its substantial equivalent. Yes 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 nos have the insurance coverage required by Chapter 142 of the Mau.General
Laws.and that my signature on this permit application waives this requirement.
Check One:
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
accurate to the best of my knowledge and that all plumbing work and installations performed under the permit is
for this application will be in compliance with all pertinent provisions of the Massach State Plumbing C
Chapter 142 of the General Laws.
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B y Type of License: i' "-- f ----
Title 0 M� -TER
attire of Licens Plu r or Gasfiner
City Town 7 a UR' NEYMAN • License Number L r
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