GP-65991 0 TOWN OF DARTMOUTH - t3�U4LDING DEPARTMENT RECEIPT "' CI t
PHONE: 508.910.1820 FAX: 508-910-1838
1/ 7/ /
i f i ` Property caner: / _. ' Date
amen . t t_-t r oP rty .,
Jo Location: f� �; d 1..= „,e mail:,
,l� Lot:
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escription General Ledger#'s Ref. # Amount
Buuilding &Building Misc. 01000-44105
Electrical 01000-44106
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Plumbing & 01000-44107 �, o /
Trench Safety 01000-44129
Other Department Revenue 01000-42420
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By ;1 it
THIS IS NOT A PERMIT/LICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAR
(7-N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY a 4/ /74-
/() MA DATE PERMIT#
JOBSITE ADDRESS /9//1/X._ L/4-At/ /2-) OWNER'S NAME
OWNER ADDRESS • _..<" /4-M TEL FAX.
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL„..k
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:
PLANS SUBMITTED: YES NO'
APPLIANCES 1 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
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES \'NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY >4 OTHER TYPE INDEMNITY , BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachuse General Laws,and that my signature on this permit application waives this requirement.
dA—,1 CHECK ONE ONLY: OWNER AGENT ,><
SIGNATURE F OWNER OR AGENT
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 that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertine t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 19/%04— /9 OP 0 Arr. LICENSE# aa
MP MGF JP JGF PGI CORPORATION # • PARTNERSHIP # LLC #
COMPANY NAME: //./ a ,„5- (172-0/0/1./1/. ADDRESS 1./.77 ex.frf it 60/1-z-c_
CITY 711/ /-0 / STATE R'J ZIP 0,;243-7 TEL Li0/- 6-2 '.?p_r'
FAX CELL EMAIL
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