PP-49466 TOWN OF DARTMOUTH
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BUILDING RECEIPTS ; "; _
COLLECTOR'S OFFICE
Name ` i-- Property , r Date: fix . /
3 It r _.L- . Owner: J` 7- i f'. ., 7
Job Location: _
Y r White Copy-Collector's Office
Plot: F Lot: 1
' ,,°------ Yellow Copy-Customer's Receipt
` k ' Pink Copy-File Copy
Green Copy Building Department
Phone:
34
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Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105 `.
\
License&Permits-Building Misc. 01000 44105
License&Permits--llecfrical 01000-44106 .
f
License&Perthits-Plumbing&Gas 01000.-44107 F;P+ %.I J1,1 f1 ,
Other Departme`1t-Re enue 01000-42420 `
This is not a Permit or License for Building,Plumbing or Gas Received By:
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
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' r� air �'Ylf�u ► Mass. Date �'" �00 '7 Permit # 9�6,4
Building Location es Jain, 7S/cr,cf Rd Owner's Name TO1,» .Je on;ems 5
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Type of Occupancy JieS de.i+4 L
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New ❑ Renovations Replacement"K Plans Submitted: Yes ❑ No ❑
FIXTURES y-®�_ q�is i;i
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< F- < < z 0 - < < O < JO OO < C Q wx, ¢ o U = a
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SUB—BSMT.
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BASEMENT - X ,
•
1ST FLOOR
2?5( I l
2ND FLOOR r
3RD FLOOR I '
I
4THFLOOR
..zr5TH FLOORI
2.2 . . . . - M , ` t
_ 6TH FLOOR _
7TH FLOOR
8TH FLOOR
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Installing Company Name Check one: Certificate
JayEan Gas 3er vice _,
Address 80 County Road Corporation '
E, Fice(Uwn, MA 02/17 /
(508) 763-2729 ❑ Partnership
Business Telephone /� ❑ Firm/Co.
Name of Licensed Plumber b ri-eta-1 Pavvv e1i +e r
- - X
INSURANCE COVERAGE:
J have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL •h. 142.
Yes No ❑
If you have ecked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ►_ij Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage requ red by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this require ent.
Check one:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or e ed)in above application are true and accurate to the .est of my
knowledge and that all plumbing work and installations pe ed un a ermit issued for this application will be in compliance ith all
pertinent provisions of the Massachusetts State Plumbi Co e and Chapt 142 of the General Laws.
_
By
Sr ure of Lice d Plumber
Title
City/Town Type of License: Master Journeyman U -
APPROVED(OFFICE USE ONLY) License Number /dg78'
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