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09758
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
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This certifies that ....................
has permission to perform.
plumbing in the buildings of
d10 .................
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at . ............. ................ , North Andover, Mass.
Fee 3-;� ..... Lic.No.h��. -M4 ................. ...
PLUMBING INSPECTOR
Check # C>2 L/
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FIXTURES
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: MA. Date:_ 12-- 1 h —_A_) -Permit# q1Q-,
Building Location: S(n C± Owners Name: A 0
Type of Occupancy: Commercial El Educational n Industrial F1 Institutional F] Residentiai.Fx1,.--*
New: Alteration: E] Renovation: F] Replacement: Plans Submitted: YesE] No E] j
FIXTURES
INSURANCE COVERAGE:
I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No El
If you have checked Yes, please indicate the t)" of coverage by checking the appropriate box below.
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
Massachusetts General Laws, and that my signature on this permit application waives this requirement
Check One Only
owner El Agent E]
Sianature of Owner or Owners Aaent
I hereby certify that all of the details and information I have submitted (or enteqvd) regarding this application are true and accurate to the best of my
Knowledge and ithat all plumbing work and installations performed under the permit issued for this application will be in
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
BY
Title
City/Town
Type of Ucense: JOk,-, 1 41 L-�L A -4,-V
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22!neyman License Number;
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10 11'�5 1'�� 'Aa'4-L--J0\ �)�' ), 4%'l -e q. �1 1�1'� %'Q " 1-� 4
DEDICATED
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Holmes Plumbing Heit-Iffig
Check One Only
Certificate #
Installing Company Name: 6 Ruth Circle
Haverhill, MA 01832
Corporation
Address: Cdyf rown:
State:
Partnership
Business Tel: Fax:
ElAirm/Company
Name of Licensed Plumber:
INSURANCE COVERAGE:
I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No El
If you have checked Yes, please indicate the t)" of coverage by checking the appropriate box below.
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
Massachusetts General Laws, and that my signature on this permit application waives this requirement
Check One Only
owner El Agent E]
Sianature of Owner or Owners Aaent
I hereby certify that all of the details and information I have submitted (or enteqvd) regarding this application are true and accurate to the best of my
Knowledge and ithat all plumbing work and installations performed under the permit issued for this application will be in
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
BY
Title
City/Town
Type of Ucense: JOk,-, 1 41 L-�L A -4,-V
lu Sj§n-9Yriof` Lici6s-edPhfrnlJ*F1
22!neyman License Number;
(DII'3 —/LQ-c`c' '-'I V��l
10 11'�5 1'�� 'Aa'4-L--J0\ �)�' ), 4%'l -e q. �1 1�1'� %'Q " 1-� 4
41
of Massoichusem
DeparhMM of Public SaIdy
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