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Date. .
pRT
;"` r '61 :'+o TOWN OkN4 ANDOVER
PERMIT FOR PLUMBING
16t
SSACMUSE(
This certifies that . . . .
'�/ j' c
has permission to perform . . . �?` . . . . . . . . . . . . . . . . .
plumbing in the buildings of . . . . . . .f. . .. .... .`. . . . . . . . . . . . . . . . .
at . . . . A. A$:� !.`."�. . . . . . . . . . . North Andover, Mass.
r
Fee. Lic. No..9.3 3.3. . . . . . . . . . . . . . . . . . . . . . .
PLUMBING INSPECTOR
Check # 7
7504
MASSACHUSETTS UNIFORM APPLICATION FOR-PERMIT TO DO PLUMBING
(Print or ype)
, Mass Da
201/ e it #
Building
o c a t i o n r � �' ,Owner's' am
Type of&copancy
New 0 Renovation❑ Replace men't{II;-,^ Plans Submitted: Yes 0 No 0
FIXTURES
B.P.-# -SEWER # SEPTIC # -
z
Z Y yQ
Ln
Z Q d} O Z = � W of
tin W U) to = cn h� U W to in U_ Z Z" z a
� W O _n W Q tW W 7- Q w ti a � Ln Z � a � � � U_
LL
_ ° z to Y O O z z t li W u_ U 0 _
SUB-BSMT
BASEMENT
1ST FLOOR
2ND FLOOR
► 3RDqFLOOR
4TH
5TH
6TH
7TH FLOOR
8THFLOOR
nstalling Company Name Check ong: Certificate
%ddress 0 Corporation
3usiness Telephone ` 00 Partnership
Mame of Licensed Plumber or Gas Fitter V,rlrm/Co.'
1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGLCh. 142..
Yes No . 0
If you have checkedyes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy � Other type of indemnity 0 Bond ❑
OWNER'S INSURNACE 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.
Signature of Owner or Owner's Agent Check one:
Owner ❑ Agent ❑
hereby certify that all of the details and-informatlon I have submitted entEfredl,in.above'apptipatlon,are tfuefand accurate to the best of
y knowledge and that all plumbing work and installations performe nd r tfte permit iss for tKs application wilt be in compliance with
.I pertinent provisions of the Massachusetts Statepiumbing Code a t 142 of the' eras Laws.
By SI nes ure of Licen ed lumber
Titles
Cityrrown j
APPROVED(OFFICE USE ONLY) 11 Type of License: 601 aster OJourneyman
License Number_ ��