PP-91145 TOWN OF DARTMOUTH#--BUILDING DEPARTMENT RECEIPT 9 1 1` LF
PHONE 508-910-1820 -Fly. ,508-910-1838
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Name: 1 j •'"" - Property Owner: i fr-f=y- '"` Date:I,'"/
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Job Location. _1 if- ,t ',ill °=3�°e _ Map: i "1 Lot:
Description General Ledger#'s Ref. # Amount
Building& Building Misc. 01000-44105
Electrical N OF DARr`•w�. 01000-44106
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Plumbing &/Gas JP & 1000-44107 �' i , �`
Trench Safety .1: 5.sr: , 01000-44129 N U
Other Departmen Revenue 01000-42420 1
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White-Collector's Office Yellow Cop etrStoinar}s Receipt Pink Copy-Building Department Received By
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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= CITY / ,3L/1 ep(e.ri- MA DATE E` ,�' �P PERMIT#
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JOBSITE ADDRESS %re1 eel OWNER'S NAME ems'��
P OWNER ADDRESS j 1 TELL IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL I . I EDUCATIONAL [ RESIDENTIAL
PRINT �,-;�
CLEARLY NEW:i RENOVATION:Li REPLACEMENT:.L _PLANS SUBMITTED: YES= NO1 A.
FIXTURES 1 FLOOR—P BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BATHTUB t }}
CROSS CONNECTION DEVICE _Y__ f fi r r r--� �[ �` ,
_:t. r��L . �tl_ � �-- FL ti '�_4.:., it �^�
DEDICATED SPECIAL WASTE SYSTEM I` !I- _ ___[ ' 1-_ ;, L 'LT 6 (� _ i!
DEDICATED GAS/OIL/SAND SYSTEM [ _. L 1 _ 1, i_ ;f - if _ j,_ ;� ;
DEDICATED GREASE SYSTEM -- 1 `LT t11 _JU 1 {1._ i _ 4_
DEDICATED GRAY WATER SYSTEM _- „_._T L_._ .,_ f �_ —! IL {
DEDICATED WATER RECYCLE SYSTEM _ J Jl _ L 11 _ 1 ,1-- 1 _J1. it a;.._
DISHWASHER i____ --TL _ J[ _ I '1 L,_ (---I1. _ i1 ')__.__,,
DRINKING FOUNTAIN I _I iL J1 I a1.._ _ -�I[-ce _ - [ L !i I _
FOOD DISPOSER �1 . i J _-_,- JET JL --y I[ - 1L L.i . J ice ....
FLOOR/AREA DRAIN I IL E _ I_ 1 . 7t ''~ ( / t
INTERCEPTOR(INTERIOR) I _ _ LI IL_11 _ETD _ ziL_ ..L-- ( :37_i .!_ iL _1 /Ci
KITCHEN SINK I..__i _ ;[ .rl E _ 1. _ [ - I -L V T
LAVATORY I r . _l 11 ._ _.I1_.'��72r i — Ji�r ______L .—_ 1��
ROOF DRAIN } �I ; _
SHOWER STALL 7 +_ ..__'i [ ,_1 0 i t. _ 1 -__ 11 )
�SERVICE/MOP SINK • 1 I t i[T 11-- l i
TOILET ► -'L L [L 11 ?L _ j[_ '7- j. -
URINAL L 1( 1 11__ il. --1: ;r 'i _ f i ,L_ l" _.-___
WASHING MACHINE CONNECTION ! I '1_ E) .1;- 1 I , jl 1 ;1__ [ II__11L -
WATER HEATER ALL TYPES I � [-�T { r j 1 fI
WATER PIPING ( I'I— tl-- �! it-_JL 1 _,� p I -' _ L r 1
OTHER P._ . _ u 1E-1 1 _. 1LI T1 11, 77 Ir I iE1` 1
• 1Efi --_i_�' __1 _ (L ii L_._11 :__ I li_T.`E i __ if,..._
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 10 I j
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 i17--- OTHER TYPE OF INDEMNITY 0 BOND 0
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 Lj AGENT Lj
SIGNATURE OF 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 compli with all Pertinent provision of the
Massachusetts State Plu bing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME ' ' LICENSE# i _e P 1 SIGNATURE
MP[ JP C CORPORATION 1-#j 1 PARTNERSHHII `1 P # 1 LLC[ #1 J
COMPANY NAME ADDRESS i be/ te„..)/Gye.- 4-
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CITY ]�/4 �y1� 1 STATE ZIP 7Jj 1 TEL 7 ��`�
FAX i CELL 1 5-erp 77,1 EMAIL 1 _ I
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