PP-46589 TOWN OF DARTMOUTH
BUILDING RECEIPTS
COLLECTOR'SDFFICE
Name: ' .," - -Property ' Date:
- Owner:
Job Location:
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Description General Ledger#'s 1 Ref.# ---- \ Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 c,
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License&Permits-Plumbing&Gas 01000-44107 - .,, 1:,-,:-
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Other Department Revenue 01000-42420 --- ---
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This is not a Permit or License for Building.Plumbing or Gas Received By:
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential rir
Owners Name f(_ .itA.. Owners Address 3 U 11n t r5 Jeer d
Building Location 31 kU1\Cllt Dees' ' ► Date CC4 giotd.o
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Renovation ❑ Replacement ❑ Plans Submitted ❑
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SUB-BSMT.
BASEMENT
1st FLOOR I
2nd FLOOR
3rd FLOOR
4th FLOOR
''' 5th FLOOR
6th FLOOR
7th FLOOR
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8th FLOOR
Installing Company Name Sugar Plumb Check One: Certificate
Address 21 Eddy Street ❑ Corp.
City N. Dartmouth State MA lip Code 02747 ❑ Partner
Business Telephone: ( 5 0 8) 9 9 3-8 9 0 3 ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter Mi chae 1 Means
INSURANCE COVERAGE: Cha#One:
I have a current liability insurance policy or its substantial equivalent. Yes No 0
If you have checked yes,please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: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 El Agent 0
Signature of 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 best of my knowledge and that all plumbing work and installations performed under the permit issued
for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
8 y Type of License:
Title ❑ MASTER Signature of Licensed Plumber
City/Town i] JOURNEYMAN License Number 21 21 4 /
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