GP-30260 TOWN 'OF I 5 cR MVIOUTH li.i 19,A
BUILDING RECEIPTS
, , ra J Fes, , ,, . QOLLECTOR'S OFFICE
Name l °, rr / M . + ,/
'PA i ' t t Property r Date t :
, 3 Owner: 1 >F`��
- Job Location: i i '` i-- _. d - -, :` ,
White Copy-Collector's Office
Plot t 7r,4 Lot: i Yellow Copy-Customer's Receipt
`' Pink Copy-File Copy
Green Copy-Building Department
Phone:
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Description General Ledger#'s Rcf to, Amount
t_ii1«1,.1:
License&Permits Building 01000-44105
License&Permits-Building Misc. 01000-44105. AUG 2 0 '''-'
License&Permits-Electrical - 01000-44106 ./11f .-- -'-‘
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License&Permits-Plumbing 84 Gases` 01000-44107 .'€j '. .. !'
Other Department Revenue 01000-42420
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This is not a Permit or License for Building,Plumbing or Gas Received By: J
' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITI1NG A
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential g 1.
Owners Name t P CGS Owners Address a.7 Pet)E -
Building Location 4-7 Pi li.- 1:" —ts-c--th-7-1� / • Date -,)•=zIt )'
New ❑ Renovation Replacement 0 Plans Submitted ❑
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SUB-BSMT.
G BASEMENT
1st FLOOR r
2nd FLOOR
3rd FLOOR
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4th FLOOR
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5th FLOOR
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6th FLOOR
7th FLOOR
8th FLOOR
Installing Company Name EF9ifi )?_2(-1-i't---S- Check One: Certificate
Address lt(-' I T -- . 0 Corp.
City fictbca3a>rs State Zip Code ?-3 4C ❑ Partner
Business Telephone: 8-6 i (t?V 2-76 0 Firm/Co.
Name of Licensed Plumber or Gasfitter Ph-b `L:T
INSURANCE COVERAGE:
'Cheek
I have a current liability insurance policy or its substantial equivalent. Yes❑ONo
0
If you have checked yes,please indicate the type coverage by checking the apptopnate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S r.'IISURANCE WAIVER:I am aware that the licensee does not hare the insurance coverage required by Chapter 142 of the Mass.General
Laws.and that my sigeawre on this permit application waives this requirement.
'i
Check One:
Owner 0 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 installatt�o rmed under the permit issued
for this application will be in compliance with all pertinent provisions of th"Massach efts State Plumbing Code.and
Chapter 142 of the General Laws. . 1
B y Type of License:
Signature of Licensed Plumber or asfitter
Title C MASTER
Citv•Town 4- OURNEYMAN License Number c2?2 3
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