PP-59173 $ H S TOWN OF DARTMOUTH
.7i v BUILDING RECEIPTS
-` `" ' PHONE: 508-910-1,620 FAX: 508-910-1838 591.73
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Name: ; Prerttu ",N° ., �`s Date:r / /
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Job Location: , j i,.3e` White Copy-Collector's Office
/t/' d / F , -/ Yellow Copy-Customer's Receipt
f t+ #� ' ... _,,, .. Pink Copy-File Copy
Map: p i Lot: Green Copy-Building Department
Phone:
Description General Ledger#'s Ref. # 'tA Amount��`
License& Permits - Building 01000-44105 1ej aN�a ikl
E 10R
License &Permits -Building Misc. 01000-44105 /
License & Permits - Electr sa 01000-44106 * -� 9 (/',1 �. -✓'
License &Permits plumbing Gas 01000-44107 , .- r ,; 0� 41 f {; '" —
License & Permits Safety 01000-44129
Other Department Revenue 01000-42420
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLUMBING OR GAS
Received By: , '`. :.7„ - ' .f.
• MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
p (Print or Type)e mown of Dartmouth
0 rn- w'a 'k ,Mass Date Z/I/ /`. 20 Permit# 5-9/7
Building Location Ld`.— LI �'vl 1 S `,-,'^ ' ----+`7 Owner's Name !-or 6h/.1 r
1 0 P'V t- t``'^ 12.-- Type of Occupancy Ae 4 , .
Newfr Renovation 0 Replacement 0 Plans Submitted: Yes❑ No 0
FIXTURES
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SUB-BSMT.
BASEMENT t
1ST FLOOR t t �'
2ND FLOOR 1
3RD FLOOR
l( 4TH FLOOR
G� 5TH FLOOR
r/ %/- 6TH FLOOR
it I 7TH FLOOR 16,
,`a .
....„,(1 8TH FLOOR
Installing,ompany Name � 1/ 71ih.,�(rrt�`I/ S ,,.�, Check of Certificate
Address 7i(o OD 0 cl I 4
CorOPRe
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Business Telephone S)3 9 573 5/ al El pp Pa !-
Name of Licensed Plumber ,�)0.6 r Sv l "i ='
❑Firminfiipany,
INSURANCE COVERAGE:
I have a cur t liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked yes,plea e indicate the type of coverage by checking the appropriate box.
A liability Insurance policy Other type of indemnity❑ Bond 0
OWNER'S INSURANCE AIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General
Laws and that my signature on this permit application waives this requirement. 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 entered)in above application are true and accurate to the be of my knowledge and that all plumbing
work and installations performed under the permit issued for this application will be in compliance with all e 'vent pr ' i s of the ssachusetts State Plumbing Code and
Chapter 142 of the General Laws.
By Signat a of is s d Plumber
Title
City/Town Type of License: Master Ae Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number +® ;Glc---..
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