GP-22417 ,_ ,-___-_,,,,-----7-,, -, -, - -------„v-_,,,:---- -_
TOWN OF DARTMOUTH 22417
BUILDING RwiEjp4
COLLECTOR'S OFFICE
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Name L.,',:,.','"7 v.,-1, z.....• , /.1,- .-- ,/," -. Property/./ I / i :r. /-..,?, ..,/(2 .,-, Date i ....j, --- / ---f ',
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Job Location: '
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WhiteCopy-Collector's Office
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Plot: 7 -s.., Lot: 4.,„. — / tf COLLECTOR'S OFFI copyi/ -",, TOWN OFnARTMO UT'tllow Cojpy-Customer's Receipt
i / File Copy
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i — Green Coy-Building Department
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Phone: 1 I 1
DEC 7 MI r,
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Description General Ledger#'s L „Re. 1 Amount
License&Permits-Building 01000-44105 -3
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical --- 01000-44106
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License&Permits-Plumbing.4-Gas 01000-44107
-._-/ -
Other Department Revenue 01000-42420
42 1.
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This is not a Permit or License for Building.Plumbing or Gas Received By: i/ 1 A
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF I H ING
DARTMOUTH,, MASS. Type of Occupancy-Commercial ❑ Residential 27
Owners Name fitv0i� lr is z- Owners Address /3 /97eJe(VaS C.�'
Building Loca ' n /.� /�fe-dC�G�S L Date l p) '' ' R000
New Renovation ❑ Replacement ❑ Plans Submitted ❑
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SUB-BSMT. X
G BASEMENT
1st FLOOR
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2nd FLOOR
3rd FLOOR
4th FLOOR
0 +! 5th FLOOR
6th FLOOR .
'' 7th FLOOR
8th FLOOR
Installing Company Name PrcfzTitie_- C.'�-l3 ..�-r"C r Check One: Certificate
Address �5 �' I ❑ Corp.
City Vs'4-5 1�'/T--- State02/`2 Zip CodeCIA* C) ❑ Partner
Business Telephone: "j Gs 67 - 7 Firm/Co.
Name of Licensed Plumber or Gasfitter ,236e0-77—
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INSURANCE COVERAGE: ''CheckJne:
I have a current liability insurance policy or its substantial equivalent. Yes No ❑
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 One:
Owner ❑ 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 pe ed under the pe "t issued
for this application will be in compliance with all pertinent provisions of the Mas c ens State UPI n Code and
Chapter 142 of the General Laws. ,_
B y Type of License: ..e4l —
Signature of Licensed P umber or Gasfitter
Title 0 MASTER
CityiTown 0 JOURNEYMAN License Number L P goy(
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