PP-66299 0TOWN OF DARTMOUTH - JILDING DEPARTMENT RECEIPT 0
PHO E. 5 - 1 `, 8?f FAX: 508-910-1838
= O ' r e .Nam f ,7,.... r t '1p ner: _. - Date / i
Job Location: / r' ° 'rt..' ` .-.i' rc1:m. A., Map: �2j Lot: 2
Description t Genera f tiger ifs Ref. # Amount
Building & Building Misc. 0I000-44105
Electrical 01000-44106
PlumGing.& Gas 01000-4410j i/ ; /s /r ..,Z. • r r-
Trench Safety 01000-41'
Other Department Revenue 01000-42420
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
MA38ACHUSETTSUN/FORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING VVORK
CITY
OWNER ADDRESS
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PRINT
CLEARLY NEW: NDVATON: REPLACEMENT: PLANS PLANSSUBMITTED: YES NO'--~�~
FIXTURES-1 FLOOR—~ aow 1 c 3 4 n O 7 o o 10 11 12 m 14
BATHTUB
CROSS CONNECTION DEVICE -------
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM 7
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL ' |
�-�SERVICE MOP SINK
TOILET
UIRINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING is
OTHER
it
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|NSVRANCErOvERAGE:I have ucunenoncupohoyorhssubs�nda/oqu�a�mtwh�hmee�the ra��ame�sofMGL Ch. l42. YES—� NO ��
�YOU.CHECKED YES,PLEASE|N0CATETHE TYPE OF COVERAGE BYCHECK�8 THE 8PPROPR�TEBOX BELOW
U8B!UTY|NSURANCEPOL|CY-- OTHERTYPEOF|NDE�N|TY �7 80N��7
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OWNB73INSURANCE V0UVEF�|omawam that the|�enamdoes not have the�smanoocovemgemquhedbyChap�rl42u[the
K0assachusousGonmn|Laws,and that mysigna0uenn this permit app|icadonwaives this requimmenL
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CHECK ONE ONL�� 0VVNERL� AGENT / �
SIGNATURE OFDVVNERORAGENT --
/he�6vce��matao�meumooy and m�nnauon/have"ubmmaucvemamu �/ m�applicationtrue u m ---
and that all plumbing work and installations performed under the permit issued for this application will
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��SIGNATU�RE
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