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T:��o TOWN OF NORTH ANDOVER
'f PERMIT FOR PLUMBING
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This certifies that .�?'.?R1t!?F� . . . . . . . . . . . . . . . . . . . .
has permission to perform . . Al . . . . . . . . . . . . . . . .
plumbing in the .buildings of . . !t t. . :° . . . . . . . . . . . . . . . . . .
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at. , Mfr < . . . . . . . . . . . . . . . . . ., North Andover, Mass.
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Fee/ r7.Lic. No.. C". . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLUMBING INSPECTOR
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WHITE: 1{ �M1C�rSY 14:21CANARY:%0jctg DPAID PINK:Treasurer
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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r^ w r'+1�6V Mass. Date �� i � 19 1�--- Permit #
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? Building Location Owner's Name
wo C Mirtak4 Type of Occupan
Newv' Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑
FIXTURES
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SUB•BSMT.
BASEMENT
lit FLOOR
,2nd FLOOR 1
3rd FLOOR
4th FLOOR
Sth FLOOR
6th FLOOR
71h FLOOR
8th FLOOR
Y ��w Check one: Certificate
installing Compan Name
Address , (3 be VCorporation
A f k g ) O Partnership _
Bustn@ss Telephone ' ❑
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Plumber
� � Plumbe L+tensed
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IN iUf '+Cf COVERAGE:
I h aver ,-nt�sbttity insurance policy or its substantial equivalent whK h mwN fie requirements of MGL Ch. 142.
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if yav 1.1 ._ e luxked yes, please i icate the type coverage by checitne Ow apprnprrare lax.
A liability Insurance policy e Other type of indemnity O t3rrnd t
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not haw*t+w m%urance coverage required by Chapter 142 of Ow IRA&-
General laws, and that my signature on this permit application waive+ thl% rtrqurrf"Ill! N. Check one-
Owner Fj Aeent
5ignature of Owner or Owner's Agent
tailmyknoI ht_. cis mh that all rw•*0 death std mrommmi,I have submitmd IO M/ltedl In ahww +M.nn w old ac the Aaa�YChu1lnti Woe
�q�rade and %ya.�a�.
a.rf,r..tsllnom peAnrttted utsde,titc'pemol issued lir this application will be m c Unca th MI
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