PP-82529 e)_
TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 8 2 5 2 9
,41 ,,,„ ,......
PHONE: 508-910-1820 FAX: 508-910-1838
)4.-)
Name: ,41 4-4 )11/4r 6eiritly e r: Date: /
''n
Job Loc on: 0 /4 ta6/if,41-41,,, -(4' Map: Lot: 1 2-
, .
Description ,i9:\Aerxia,,..140:1 er#'s ‘
t26, Ref.# - ' — Amount
Building & Building Misc. f
01.0140-44fb
Electri0-, 01090-44.106
,
Philteint Gas 01000-44107) 1,3,..c, /bit o
, '
tf
Trench Safety OWN.441,2'9
Other Department Revenue 01000-42420 .---,
,
i
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received 10 4" : ---------
i
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PL' BING OR GAS
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1u�y, �, CITY .e-f_-�0-=f - Mk DATE_ .a / PERMIT#
JOBSITE ADDRESS j.,5,/l:,v.e �:Lr .s._ L L Q_ :1 OWNER'S NAME
OWNERADDRESS: ,
P l 1
- � i�e��.c�'0S �..43-L�, ..-- :,-- - _ TEL ...,_ FAX. :. . � ,- - 1
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL El C—RESJDENTIAL)a-
INT
CLEARLY EWE[ ' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 0 )
FIXUTRES 7. FLOORS-+ smut 1 2 3 4 . 5 6 7 8 9 1B- 11 12 13 '14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER ' /
DRINKING FOUNTAIN )
FOOD WASTE GRINDER UNIT
FLOOR/AREA DRAIN /
INTERCEPTOR INTERIOR /
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING --
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ® NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box Flow.
LIABILITY INSURANCEPOLICY pt OTHER TYPE INDEMNITY p BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the _
Massachusetts General Laws,and that my signature on this permit application waives this requirement •
. CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have subniitted(or entered)regarding this application are titre and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this appli lion will in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws
PLUMBER NAME: J tv Is •- 5 r _ LICENSE#J:_i.i_Z}f_._ SIGNATURE
COMPANY NAME: 'S ,M � __F�°1 ns__'i v\c_- -- ADDRESS: A% ....,- - -
CITY:1.._ lei" . : _.. . STATE: ► _ : ZIP: lya2`7 32 ___ _ _I FAX
TEL: ` _ 7.4o G CELL- , Y`r_� a F,90 t EMAIL:I.t'Cu �K >g L r� /f14c0, c u c
MASTER,A JOURNEYMAN❑ CORPORATION D3# o 7 j. .'PARTNERSHIP❑# ,__ - _ _ LLC❑## .--.--= _..--
•
• .. -•-. ',---••.-- -.- - . - . - . \ . 5
•
z
z
•
o
Vl
•
?' r
roo p
•
r ul
D C
E
moo
_® . ``
43
N.
11
- O
y z
z
g