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MASSACHUSETTS UNIFORM APPLICATION POR PERMIT TO bO PLUMBING
(Print or Type)
e�-P-Mass. bate 19 %3 Permit #
Building Location %% --JL� Owner's Namer
s• Type of Occup�L-
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New ❑— Renovation ❑ _
d a r
Replacement EJ— Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name Welch Brothers Co, , me Check one: Certificate
Address 48$ Corporation 15 01 – C
T. n w A 7 1 Mar g l 8 5 l ❑ Partnership
13usiness telephone (5 0 8) 453-2100 ❑ Firm/Co.
Name of Licensed Plumber T h n m a z g( a r e y
INSURANCE COAAAGE:
I have s current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ® No ❑
It you have checked yea, please indicate the type coverage by checking the appropriate box.
A liability insurance policy W Other type of Indemnity ❑ Bond ❑
OWNtAl INSUAANCE 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 ❑
Signature of Owner or Owner's Anent i'1 /i
I hereby certify that all of the details and Information I have(or enl
knowledge and that all plumbing work and Installation orme nder the
pertinent provisions of the Massachusetts State Plu In Cod d Chapter
By
ignaure o cense um
Title
City/Town Type of License: Master
APPP4OVE O C ARCO Yj License Number
In abo ap tion are true and accurate to the best of my
t Is d is pplication will be in compliance with all
NOV 2 9 1993
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SUB—esMT.
BASEMENT
1$T FLOOA
2NOFLooR
3RDOLOOR
ATH FLOOR
5TH FLOOR
BTHFLOOR
7TH FLOOR
9THFLOOR
Installing Company Name Welch Brothers Co, , me Check one: Certificate
Address 48$ Corporation 15 01 – C
T. n w A 7 1 Mar g l 8 5 l ❑ Partnership
13usiness telephone (5 0 8) 453-2100 ❑ Firm/Co.
Name of Licensed Plumber T h n m a z g( a r e y
INSURANCE COAAAGE:
I have s current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ® No ❑
It you have checked yea, please indicate the type coverage by checking the appropriate box.
A liability insurance policy W Other type of Indemnity ❑ Bond ❑
OWNtAl INSUAANCE 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 ❑
Signature of Owner or Owner's Anent i'1 /i
I hereby certify that all of the details and Information I have(or enl
knowledge and that all plumbing work and Installation orme nder the
pertinent provisions of the Massachusetts State Plu In Cod d Chapter
By
ignaure o cense um
Title
City/Town Type of License: Master
APPP4OVE O C ARCO Yj License Number
In abo ap tion are true and accurate to the best of my
t Is d is pplication will be in compliance with all
NOV 2 9 1993
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• Date.
�1
°f+H0T .�"c TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACMUSE�
This certifies that .... ! ... (b.J ....I.. ;f.•..�..
has permission to perform ..............
plumbing in the buildings of ... , '..:��.'.......��. !::.�!:... ?..... .
at .... e. ..... ` �...... , North Andover, Mass.
'
Fee. . . ,..... Lic. No... . ....... !..'.:
Y
PLUMBING INSPECTOR -
15.0 P-41"
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File