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GP-49465 _ • 11 il fl iNFITA/TeDi_JT-f-f- 7--- ------ .1111115210111.1111110111111111111111"-- ---- . E ��- G 11. - I ___ Date. - Job Location: ' - _ t.. _,-- Collectors Office t -- Yellow a',.or's Receipt - _ - i S jl _ Pink Copy-rieGop�y - 9 - - - 2 e --.:a -- Green Copy-Building Department 3 l i . 7 _ - o Description General Ledger#'s 's, Ref.# amount License&Permits-Bu�t�ng z --- ' _ i 10-44105 dcP -Building Misc. 01000-44105 = _.,. r'__r • If - I e&P!®mik-Eleet�eal �__-- O1000-44106 {' License&Permits-Plumbing&Gas 01000-44107 f y / /' j 5 J • Other Department Revenue '-- -.r 01000-42420m�:. '` This is not a Permit or License for Building,Plumbing or Gas Received By: >"_- _ ''' ., MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING z. DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential Y X Owners Name -J O H J e 0 1/1'^S s Owners Address e9 5 e .2"S 4+c/ RI Building Location ,�A N Date '-e R© 7 i (.4 New ❑ Renovation js Replacement 2 Plans Submitted ❑ to cn vi v) u z E4 o w W CID H x x _ = cip = W W 0W W c1 C7 E-1 Z W H ZW W C7 W a ,F W W Z Q u1 = Q p4 E-' � (4 OZ OtoZ ''� ¢¢ W � W ZQx QQ OOW OW H I� Z O L7 Z w A AO a U a4 9 A as E-, O SUB-BSMT. BASEMENT X 1st FLOOR 2nd FLOOR 3rd FLOOR 4th FLOOR 5th FLOOR .-1-C---.' 6th FLOOR 7th FLOOR i Allk, / 8th FLOOR , ,i, Installing Company Name Check One: Certificate f Address 8u COuniy Road.: Corp. E E. Treetuwn, MA 02717- } (608) 763-2729 I CityOr State Zip Code n Partner v / n Firm/Co. Business Telephone: Name of Licensed Plumber or Gasfitter /R 5 PI.5.je y INSURANCE COVERAGE: Chec One: 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 a ropriate box. A, i__„ A liability insuranceli Other type of indemnity Bond 1\ d OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General 11 Laws,and that my signature on this permit application waives this requirement. r Check One: Owner ❑ Agent ❑ 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. / '�� � �!�-�" • B y Type of License: p Sign re of Licensed Plumber or Gasfitter Title ❑ MASTER �� , _ City/Town ❑ JOURNEYMAN License Number 5 ? 4- z ri) ill o 0 A 4:4Q .:, U A a A w 1 .---.1_ AA rA cA ail a° & \ Q' Om Ci K. A z L. 4 N0 E„ .kss,, li ‘ o U a. W C7 z ` x t, WO0 \ A '• `-`:' A F w Z LY.a zgo ai Q�g gz F a . ` z Cal ¢ R H O U E, A C;'.-, W E- . -4 a �_..-� g Z t CO W I C-ceil � TT �IIIIIIII z z�, 40Y.tQ.40. a i 4 CA W x U F