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",°l?'"�4, TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
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This certifies that ,�J. .�. �! •�•
has permission to perform . . . . . ... . . . . . . . . . . . . .
plumbing in the buildings of . . . . .: !!. '. • (. . . . . . . . . . . . . • • • • • •
at . . . �. ,• . . •�•" • • • • • • • . . ., North Andover, Mass.
Fee. Fk.' .Lic. No.. . A L . . . . . . . . . . . . . . . . . . . .. . . . . . . .
PLUMBING INSPECTOR
Check # t
5416
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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Xe. "DBMass. Date /'9 m,2 y- O Permit #
Building Location .4k /1-1 O D Y S T. r Owner's Name A d K t L_
- '� Type of Occupancy
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New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑
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SEWER# FIXTURES SEPTIC#
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r BASEMENT '
IST FLOOR 1 (1
2ND FLOOR I 1 1
3RD FLOOR
4TH FLOOR I
STH FLOOR I
6TH FLOOR
7TH FLOOR
STH FLOOR Iai ffi
Installing.Company Name Q 47, Z? Check one: Certificate m
Address -j*3 Cil/"Y X4AA ❑ Corporation
/�� ?h�/IE.0 /'1�3 Bl�yy ❑ Partnership
Business Telephone 9 is'' ?I - I S %S /Co.
Name of Licensed Plumber _c7—,0/YA! !�� /�/C Ti��ill 7-40411
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked Yes, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy 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:
Signature of Owner or Owner's,agent Owner ❑ Agent El
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 performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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Signature of Licensed Plum r
Title
Type of License: Master Journeyman ❑
APPf�p OFFI USE ONLY) License Number
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