Loading...
GP-96977 TOWN OF DARTMOUTH N BlJi 6 � r s!EP�RTMENT RECEIPT PHONE: 508-910160 1,FA k0 •1 3 E tJ r. akry' v9 Name: ,' _'/', ('�' >, ' 'Property Owner: , ) .1.. it i- Date._. r �'.' r` t nt. ` ,` i 1 / ,,/ _i /f ,/ €)) =.ae QF a r t ,' Job Location: i ! ') -f-�-J I t 'I:f , s,..i'`- _ 17a1 p,,� Lot: ,,y_. ii. Description General Ledger# s Ref. ## Amount Building & Building Misc. 01000-44105 \ / Electrical 01000-44106 �J 6 �f �<�'Nr. o OLI E�\ PlumbingGas) 01000-44107 t' Trench Safety 01000-44129 Other Department Revenue 01000-42420 _ /. White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By - ' ti p, THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Wit-ge CITY /, /ffei/C/iCik MA DATE /1 9 Ti/� 6 6 / PERMIT# l"" JOBSITE ADDRESS Jr /V Z✓,y/4 /16 OWNER'S NAME cla 070,,1*146;-' GOWNER ADDRESS TEL f®c9 f6/7.3 - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL 2----- PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER -''Ni COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FUR l FURNACENACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN, z POOL HEATER Cr-- ROOM!SPACE HEATER ROOF 1'OP UNIT TEST ( Y UNIT HEATER 1 UNVENTED ROOM HEATER rJ WATER HEATER //� OTH f �Ag < J 3 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ©.•-------- OTHER TYPE INDEMNITY ❑ BOND ❑ 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 com ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE#//Irfr SIGNATURE MP MGF❑ ElJGF❑ LPG' ElCORPORATION El# PARTNERSHIP El# liz, LLC❑# COMPANY NAME Aqf'� G�'�l�iP ADDRESS i 0(1(0-416.-----0/�' CITY , /f ,1i4 STATE/,I ZIP ? 7,2719' TEL FAX CELL ree 7Fr',fi( EMAIL JO71 C - e2,1C� 1-, ��7- } ' r 7 • • sM t W , 0 z z a cen z w • °❑ z z W '�Od W >- OF a Z U w W� W co w �W O > a W Q W c g a a a ci) x J a w = w F—,co E"i 0 z z 0 F A•, C7 0