GP-59482 „i�, . TOWN OF DARTMOUTH
BUILDING RECEIPTS '
9PHONE: 508-910-1820 FAX: 508-910- 38 c
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Name 1 ya r'` r - Property / ! ,,' ,, j.' ,.,., -,mow Date. / j
- j -.4,--�' Owner: -- --/7/ t/ /'?::'-'f C,'
Job Location: ,/'- ,r' ,,' White Copy-Collector"s Office
r r >L - - , , r,.”< Yellow Copy-Customer's Receipt
} Pink Copy-File Copy
Map: �' Green Copy-Building Department
Map: /i Lot: .. t'
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Phone:
Description General Ledger#'s Ref.# Amount
License &Permits -Building 01000-44105 i-
License & Permits -Building Misc. 01000-44105
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License & Permits -Electrical 01000-44106 ' '
License & Permits -Plumbing & Gas 01000-44107 4_ ' ''
License & Permits - Trench Safety 01000-44129
Other Department Revenue 01000-42420
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING,.P. -UMBING OR GAS
Received B af _..-
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
' (P ' t or Type) '"o°wn of Dartmouth
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�6(J/• ,�C�� .Mass /Date � �' 20 /� Permit# fie,,
Building Location 1 U `Y/�16 .. C u6 / Owner's Name ) (> 60/4--T /7/A'"f 7
Type of Occupancy v/0 =-
New Renovation 0 Replacement 0 Plans Submitted: Yes ❑ No 0
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SUB-BSMT. �
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BASEMENT V�
1ST FLOOR /'
2ND FLOOR /`
,/ 3RD FLOOR
/ 4TH FLOOR •
a5TH FLOOR gr°° �'_,�
6TH FLOOR 4
7TH FLOOR
zsj8TH FLOOR 'a' ;',
Installing Compan Name, 72.1/2.4d �� Check one: rstificate
Address / 1%/ (—) Ck 72.- tiff y 'N
l� o A- dJ 777 LCorporation �
Business Telephone S Y_,) 441 I q� CI
Name of Licensed Plumber or Gas Fitter_ ci �J L ❑Firm/Company
VSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements ofMGL Ch. 142.
Yes No
you have checked +Les,please indicate the type of coverage by checking the appropriate box.
liability Insurance policy❑ Other type of indemnity 0 Bond❑
WNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General
aws and that my signature on this permit application waives this requirement. Check One:
Owner❑ Agent❑
gnature of Owner or Owner's Agent
Breby certify that all of the details and information I have submitted(or entered)in above app ' n e rue and accurate to the b st of my knowledge and that all plumbing
gasfitting work and installations performed under the permit issued for this application will be in co Pli ce with all pertinent provi 'ons of the Massachusetts State Gas
de and Chapter 142 of the General Laws.
y • Signature of Licensed Plumber
itle -
ity/Town Type of License: Plumber ❑ rj4-Gasfitter
PPROVED (OFFICE USE ONLY) a er CI Journeyman IDLicense Number
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