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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that &444-�. ..............
has permission to perform -1,344
plumbing in the buildings of
.............
at A'A4Le-.^, North Andover, Mass.
Fee. Lic. No..
PLUMBING I SP CTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING.
City/Town:_ /y�r��/� MA.
Date: Permit#
Building Location:
Owners Name:
P , Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
I I New: U Alteration: ❑ Renovation• ❑ Replacement: Plans Submitted Yes ❑ No
FIXTURES
DEDICATED
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SYSTEMS
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SUB BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4T" FLOOR
5T" FLOOR
6T" FLOOR
7' FLOOR
8T" FLOOR
Installing Company Name: `igrl�i�j_/� ��C Check One Only Certificates#
Qom] / ,�G]'Corporation
Address: -1V / C /Aj�� �� (�
' City/Town• /179J�% State: 1
p EI Partnership
Business Tel:-.�p � pax:
❑Firm/Company
Name of Licensed Plumber:
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 of coverage by checking the appropriate box below.
A liabilityInsurance policy `
p Y' 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
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
1 hereby certify that all of the details and information I have submitted (or entered) regarding this 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Type of License:_
1
Title Plumber Signature of Licens Plumber
City/Town Master /��
APPROVED (OFFICE USE ONLY! Journeyman License Number: