PP-96976 doii, TOWN OF DARTM _ - DJ p PAMENT RECEIPT
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Name: ::•‘ , , ' , ' ,i't1P-, ' . Property Owner: : -1,ii),;1,,;,,!',,,." .," [1 i ,',/ Date
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Job Location: / I , , ',. , - ! ,, , .' f , , ! Map:------- .f/ Lot:
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Description General Ledger#'s Ref. # ', Amount
Building& Building Misc. 01000-44105
Electrical 01000-44106 \\
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Plumbing'& Gas 01000-44107 f: . :. ',.,Qa ,---"" f',0 u„-
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'---Trencti''Safety 01000-44129
Other Department Revenue 01000-42420
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White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By '„:./-:: `;;:p-' 7',/,
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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lW— / ��'"r ' MA DATE %/y/0� PERMIT# p ~ 7
CITY/TOWN Z ��'
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JOBSITE ADDRESS //f/ie" '5/eii fd d OWNER'S NAME f) ( �/(e- /,/fr'-'
P OWNER ADDRESS TEL7®1176/7?le FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO gr
FIXTURES 1 FLOOR-) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 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 / (---:_„„,)
DISHWASHERl'
DRINKING FOUNTAIN /
FOOD DISPOSER al
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) ',�
KITCHEN SINK / /
LAVATORY / /
ROOF DRAIN /// �
SHOWER STALL G
SERVICE/MOP SINK
TOILET /
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
0
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESO 0
A
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a OTHER TYPE OF INDEMNITY a BOND a
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 my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co ,;Ham- with all Pertinent provision of the
Massachusetts State PI
LICENSE l bing Code and Chapter 142 of the General Laws. / -7/PLUMBER'S NAME yl� C�6' ' # 1
y SIGNATURE
MP[ ' JP a CORPORATION❑# PARTNERSHIP❑# LLC❑#//Vie
COMPANY NAME ADDRESS 1/fg.'A/6" I .f
CITY f/r,41/1/"C-- STATE I ZIP ar 4717 TEL
FAX CELL*0'710, 151( EMAIL dt,,,YCa'e ece,„ I I`1irle i`
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