GP-65548 f TOWN OF DARTMOU BUILDING DEPARTMENT RECEIPT 65606
PHONE: 508-910-1820 FAX: 508-910-1838
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Name/,.
r - "' -4,-( 1 t". , fir perty Owner: 7 \--' Date:
Job Location: / j j n s�j r tf Map: ' Lot: ••'r
Description General Ledger#'s Ref. # Amount
Building & Building Misc. 01000-44105
Electrical 01000-44106
Plumbing & as -- 01000-44107 j j; s j j'�'f;; i�2
Trench Safety 01000-44129
Other Department Revenue 01000-42420
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By r E,„,#
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL,AiJMBING OR GAS
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= .08-910-1820 FAX:-598‘910-1838
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Description General Ledger#'s Amount
Building & Building Misc. 01000-44105
Electrical 01000-44106 ,- - JAN .` 4 2012
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,„-Plumbing &/oas / ,,,
01000-44107'4'. ft„\--e„,Ai iiati. . 6,1,7„ 6,3 9, 1
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Trench Safety 01000-44129 / _
Other Department Revenue 01000-42420 .4';'.
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White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By 1i
i
THIS IS NOT A PERMITILICENSE FOR BUILDING ELECTRICAL, PLUMING OR GAS
•
- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY �4 c ntro ti k F� 11'1'k t MA DATE O I-Z`�^ LZ
PERMIT# Z., %3 Y�
JOBSITE ADDRESS S 5 P+ n-r OWNER'S NAMES I i`L<t.b e`v <` '5c?Li Z4_
G OWNER ADDRESS LOD i-ue-y 2-.rtfi Rai. .r'le
TELgO g—991.'66F)®FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL : ✓RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: V REPLACEMENT: PLANS SUBMITTED: YES _ NO'V
APPLIANCES Z. FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
-
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
•
OWEN •
POOL HEATER •
• ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
A UNIT HEATER
JNVENTED ROOM HEATER
WATER HEATER
'OTHER.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IV NO i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
1' LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND I
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 '--
SIGNATURE OF OWNER OR AGENT
I 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 thasact alls t s State work mb n iCodea nd haptor 14 under the the permit issued for this application will be in li ce wi all P ent pr n of the
Massachusetts State Plumbing Code and Chapter 142 ofn the General Laws.
PLUMBER-GASFITTER NAME B r U C e 3, A C r tJ(1Lt
LICENSE# �.3 9 e 9 SIGNATURE
MP MGF JP JGF LPG! V CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:' roc au . . Pt-c�tJ�ar-t�ADDRESS
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CITY 1— i ttl e Coat f STATE , ZIP 65213 37 TEL It 0 I 9 ,:r Lt 0 4
FAX CELL N...935 10?MIL. . ._
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