HomeMy WebLinkAboutMiscellaneous - 100 BEAR HILL ROAD 4/30/2018I
X 4559
Date.'. ......
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ....... �- +` ........F ....................
has permission to perform .'... `.E:. -.., = ............
plumbing in the buildings of .................
,at ........ North Andover, Mass.
Feer ...... Lic. No.fY-;U ..........
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type/)
M0 !� ��� �✓'L . Mass. Date 3//3 )4/ � // Permit # �T
Building Location (00 AeA t t'i r L -C— 2 ;1 Owner's Name &C- N41
1u 0 tA Nip LQ- Q 01 c,A Type of Occupancy /�r 51 D E ti ri r-1 L_
LN
New ❑ Renovation ❑ Replacement 2 Plans Submitted: Yes ❑ No ❑
FIXTURES
l
Installing. Company Nam(rM 4 TAe-f
Address �� r Cc: /4 C H /)1r1 n) y- P
Fn10 vYl f4 - v t fi cl�l
J iness Telephone
tane of Licensed Plumber
Check one:
❑ Corporation
❑ Partnership
9-flim/Co.
Certificate
6 'JRANCE COVERAGE:
I �:Ve a curInsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yreht �'ability insurance
C3' No ❑
If you have checked Yes, please
/indicate the type coverage by checking the appropriate box.
A liability insurance policy 1d' 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 ❑ Agent ❑
Signature of Owner or Owner's Aaent
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 ormed under the permit issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g e and apter of the oral Laws.
�' 'ZisLu.d
Title
re of Ucensed PluffiFeF
Type of License: Master % Journeyman ❑
City/Town _
APPROVED
(OFFICE USEONLY) License Number 235
I FA
NEI
Installing. Company Nam(rM 4 TAe-f
Address �� r Cc: /4 C H /)1r1 n) y- P
Fn10 vYl f4 - v t fi cl�l
J iness Telephone
tane of Licensed Plumber
Check one:
❑ Corporation
❑ Partnership
9-flim/Co.
Certificate
6 'JRANCE COVERAGE:
I �:Ve a curInsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yreht �'ability insurance
C3' No ❑
If you have checked Yes, please
/indicate the type coverage by checking the appropriate box.
A liability insurance policy 1d' 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 ❑ Agent ❑
Signature of Owner or Owner's Aaent
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 ormed under the permit issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g e and apter of the oral Laws.
�' 'ZisLu.d
Title
re of Ucensed PluffiFeF
Type of License: Master % Journeyman ❑
City/Town _
APPROVED
(OFFICE USEONLY) License Number 235
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