GP-66298 0-' TOWN OF DARTMOUTH, --WADING DEPARTMENT RECEIPT ° .. r' '
PHONE: 508-910-1820 FAX 508-910-1838
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Name: f l t 7i ,'A i" %ii or ty;Owneri',f 1 ... 3 Date 7/
Job Location: s v G `�'° 1 Ian; / Lot: )
Description Generuj,LetW#'s` Ref. # Amount
Building &Building Misc. 01000-44105
Electrical 04000-44106
Plumbing & Gas 01000-44107 j� L� -/f: �; ,'l?
Trench Safety 64,
01000-44 ° ''''
Other Department Revenue 01000-42420
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By , J
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRIC;PLUMBING OR GAS
1`, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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$" CITY /�1""`����� MA DATE "`
�{ o'��Pv 42- PERMIT#
JOBSITE ADDRESS 7$ /A/ /S/mod Px� OWNER'S NAME �e.SSE .S / 5
GOWNER ADDRESS "`7 S'_ ""-ti''z' �"7starrQi'. ��4 _ TEL _. FAX
_ TYPE OR -OCEIJANC-Y TYPE COMMERCIAL EDUC*T-IONAL - -R€ IDBIT1-
PRINT —CLEARLY '.--
NEW RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO V
APPLIANCES 7. 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/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER -
UNVENTED ROOM HEATER
WATER HEATER,
OTHER '.
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INSURANCE COVERAGE
I ha ent liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES G NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND h.
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 -kfiowleage
and that all plumbing work and installations performed under the permit issued for this application will be in complia ce ' . I inent pr 'sion f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 1/!['701 s %"'
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LICENSE#` � ,�� SIGNATURE
MP MGF JP JGF LPG! CORPORATION A PARTNERSHIP # LLC #
COMPANY NAME: /7/, 1/5/4"41414167 ADDRESS f°I
/-1�Sd a-5 St'
CITY /),447-14 6tirt''
STATE /-7G4 ZIP 602tic) TEL 3-7
FAX CELL EMAIL
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