Loading...
PP-74772 TOWN OF DARTMOUTH - BUILDIN.GEPARTMENT RECEIPT 7C1417.:), . 1 2 PHONE: 508-910-1820 FAX: 508-910-1838 /-!JJ G'•'t (1144 ' w Name: ,;� �' ! ,. 4 Property Owner•-�''� ,r I�ate`��, `1 ,� f L. 'Job Location: - I - i --- Map: Lot Description General Ledger#'s Ref. # Amount Building&Building Misc. 01000-44 DAR/4o0 Electrical 0100944106K y Plumbing& Gas 0100Q-44$tel `¢ t'" / .1 y r',r .. 6: ) Trench Safety 01006-44129 6 Other Department Revenue 01000-424 White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By THIS IS NOT A PERMITILICENSE FOR BUILDING ELECTRICAL PLUMBING OR GAS , , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK `°_ CITY jig C /%4dur` . _. MA DATE: �7: 7 7 PERMIT# fr JOBSITE ADDRESS ' j g e j /"e . - _.! _�_ . ) !c OWNERS NAME_��Pv t V I^! 11n©_ I OWNER ADDRESS ; i TEL FAX!(_________-______I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL w RESIDENTIAL' PRINT CLEARLY NEW:L(RENOVATION: __ REPLACEMENT!!T? PLANS SUBMITTED: YES€...I NO' FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB is ; . CROSS CONNECTION DEVICE : -I DEDICATED SPECIAL WASTE SYSTEM L !i i. ~' DEDICATED GAS/OIL/SAND SYSTEM ;I. '! ' DEDICATED GREASE SYSTEM I .._._-- DEDICATED GRAY WATER SYSTEM _ ,- / DEDICATED WATER RECYCLE SYSTEM ;- ' •DISHWASHER . DRINKING FOUNTAIN --;,"--Ti ~ FOOD DISPOSER _ ._ ,___ FLOOR/AREA DRAIN I I I....:_ - I INTERCEPTOR(INTERIOR) - i `'— L ' KITCHEN SINK l i LAVATORY _.. _ - -..TI--- 1 ,ti ROOF DRAIN 1 . r )! SHOWER STALL _ ._...__ _.._.:__.• -;; - -- SERVICE/MOP SINK = i it [I. [._._ TOILET I I a _ _ URINAL • i ; ( _31. ;; WASHING MACHINE CONNECTION I r WATER HEATER ALL TYPES ,I !' WATER PIPING _, _ li il:. OTHER 1` II I l ' .i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ti(NO LIi, IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POI.LGY OTHER TYPE OF INDEMNITY :b_j BOND ' II OWNER'S INSURANCE WAIVE r 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 L-, AGENT [T 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 t e est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in con pliance all Pe e provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - 1-7 PLUMBER'S NAME; P/ p _n) _ C_.-C_____J LICENSE# % d1 i SIGN RE MP' JP L.- CORPORATION ,#i PARTNERSHIP '#[ )LLCEI#1 I COMPANY NAME P,v:s efon..t,>v- :7 flf-,• I ADDRESS. j CI-TY;,__c lr'tik.tc^.) ----- - ._. 1STATE ! I /f ZIP d 7l 5. ._. _._ TEL �C ir ��2:_L�21,3..�. FAX ' CELL ___._._ ____.__. ;EMAIL i J r l� \� L • � z c " f* a W .I O a at z 'W Li r OW < a w co i ► z 1-1z � . 0 W F- c_ J a n. ¢ sn � w F O z 4 z 0 U W a z e4 Ca �.