HomeMy WebLinkAboutMiscellaneous - 181 LACY STREET 4/30/2018N_
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Date..'.`.: z-. c . � .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..... 5 . ....................................
has permission to perform .... ........................
plumbing in the buildings of ... "Ie
. . 4. r —
.......................
at .../. i R c. ............ North Andover, Mass.
Fee ... Lic. No.. .......... ; ......
PL6MBING INSPECTOR
Check #
r
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING33 r
(Print or Type)
Mass. Date G GCS Permit #_
Building Location Owner's Name ` 41
Type of OccupancyE'1 TI �'l C—
New ❑ Renovation ❑ Replacement Ifs' Plans Submitted: Yes ❑ No ❑
0
FIXTURES
Installing. Company Name (r^4TAe-o Check one: Certificate
Address ���; C0404m4n) -A-) ❑ Corporation
/r E TW 0 6-A-) A O tTVLI ❑ Partnership
Business Telephone-7� -��7 d qi' i n/Co. �-
Name of Licensed Plumber 'r4 F; 6 F,2 T h+ �A,vldvlr9 �Kl �cl
INSURANCE COVERAGE:
1 have a curregfiability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ '
If you have checked ves. please
/indicate the type coverage by checking the appropriate box.
A liability insurance policy fid" 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 ❑
I hereby certify that all of the details and information 1 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 issue,for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g e and apter of 77�7,
ws.
By
SLOafire of Licensed Plum er
Title
Type of License: Master Journeyman ❑
City/Town
APPROVED (OFFICE USE ONLY) License Number 233 1
������������■ems■���������■�
Installing. Company Name (r^4TAe-o Check one: Certificate
Address ���; C0404m4n) -A-) ❑ Corporation
/r E TW 0 6-A-) A O tTVLI ❑ Partnership
Business Telephone-7� -��7 d qi' i n/Co. �-
Name of Licensed Plumber 'r4 F; 6 F,2 T h+ �A,vldvlr9 �Kl �cl
INSURANCE COVERAGE:
1 have a curregfiability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ '
If you have checked ves. please
/indicate the type coverage by checking the appropriate box.
A liability insurance policy fid" 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 ❑
I hereby certify that all of the details and information 1 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 issue,for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g e and apter of 77�7,
ws.
By
SLOafire of Licensed Plum er
Title
Type of License: Master Journeyman ❑
City/Town
APPROVED (OFFICE USE ONLY) License Number 233 1
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