GP-590847 ;aP °° H y0_:: TOWN 8F ARTMCJUTH
a, ` y BUILDING RECEIPTS
` ,PIjO;NE: 508-910-1820 FAX: 508-910.1838
Name: Property Date: /
Owner: . . / c:� °d �( r
Job Location: /14:"ie Vat-White Copy-Collector's Office
1 1 Yellow Copy-Customer's Receipt
Pink Copy-File Copy
Map. Lot; Green Copy-Building Department
4/L. '
Phone:
Description General Ledger#'s Ref. # �.P Amount
License &Permits - Building 01000-44105 Q'C� v
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4+ cam:,
License &Permits- Building Misc. 01000-44105
License & Permits -Electrical 01000-44106 a '.)
License & Permits - Plumbing & Gas i 01000-44107 ' ��,,,,, €
License &Permits - Trench Saf ty _.,,.- ' 01000-44129
Other Department Revenue 01000-42420 .
.THIS IS NOT A PERMIT OR LICENSE:FOR BUILDING, PLUMBING OR GAS
,{:Received By
F MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
j (Print or Type) Fawn of Dartmouth
,Mass Date // d- 20 ( ° Permit# .. Q&.
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Building Location -5 L./riltNU/Y1J6 b c<l Uc i Owner's Name- /1 5 0 euf _ s- r i=1-Ce_--
Type of Occupancy j"C
New D- Renovation E Replacement 0 ritalltigailid.i Yes 0 No 0
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SUB-BSMT.
BASEMENT I I / L
1ST FLOOR rl
2ND FLOOR !
3RD FLOOR
4TH FLOOR
�6 5TH FLOOR _
6TH FLOOR
4�� T1H FLOOR
-08TH FLOOR
Installing Company Name ;CSC) J_L�J(7`/2 7 Check one: Certificate
Address 6 .J 0•S/-f l 11 t'rLf Z c JC S I-,k-' ❑ Corporation
_i i, A f',-r2T pi L v 1-1-1 /110
Business Telephone S-'o° -9. -:4' - - -_�(7 c1 5 ) 1 a 4:'a ❑ Partnership
Nvine of Licensed Plumber or Gas Fitter_ f j U 3 C L L=-LJ i1? z 0 Firm/Company
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes i1,^..-- No 0
If you have checked yes,please indicate the type of coverage by checking the appropriate box.
A liability Insurance policy❑ 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 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 best of my knowledge and that all plumbing
or gasfitting work and installations performed under the permit issued for this application will be in compfiance with all pertinent provisions of the Massachusetts State Gas
Code and Chapter 142 of the General Laws. (•. ;7 2/B ,
y Signature of Licensed Plumber,
Title -
City/Town Type of License: Plumber irk--
Gasfitter ❑
APPROVED (OFFICE USE ONLY) 17
Master GI Journeyman 0
License Number //(3 _�
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