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AP
�. Date .,.:�:.'x'G. .
N°
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that _-!- G:� f
.:. . -'. ...... .r .... .
has permission to perform .`�`.".:_----�-j .............
plumbing in the buildings of .............
.......... ,North Andover, Mass.
Fee.,.?. �N�.Lic. N6�`x��3�...��,,�z - :...........
y PLUMBING'INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
t
MASSACHUSETTS UNIFORM APPLICATION FOR RMI TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location ( Ul�/�o 5/� Owners Name flvom.i Permit # L5
Amount
Type of Occupancy
New Renovation Replacement 0 Plans Submitted Yes11 12
No
FIXTURES
(Print or type) Check one: Certificate
Installing Company Named/>/a11� �/ USI '�: '� s/ Corp.
Address �D X -5 72— Partner.
Business Telephone ' j -r, SD r Firm/Co.
Name of Licensed Plumber-
Insurance
lumberInsurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy N Other type of indemnity 11Bond
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I 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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plu�g Code and Chapter 142 of the General Laws.
Title
VED (OFFICE USE ONLY
Type of Plumbing License
,2c4 E9.33
►censerqumner Master ❑ Joumeyman FT
•
WIM-731
OWN
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ON
OWWWWWWWOMMONNOWINNOMMM
1 '
.........................
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..................
ON
NOWNWOMMONNINNOWN
NNONOMMONNOMINNON
(Print or type) Check one: Certificate
Installing Company Named/>/a11� �/ USI '�: '� s/ Corp.
Address �D X -5 72— Partner.
Business Telephone ' j -r, SD r Firm/Co.
Name of Licensed Plumber-
Insurance
lumberInsurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy N Other type of indemnity 11Bond
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I 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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plu�g Code and Chapter 142 of the General Laws.
Title
VED (OFFICE USE ONLY
Type of Plumbing License
,2c4 E9.33
►censerqumner Master ❑ Joumeyman FT
Date �./la .�.....
TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
p
i
I certifies that��1� ..........
Pas permission for gas installation
in the buildings of .. % `! .':�-t. ,�!'.................. .
at �� . ....: `� ..:............ . North Andover, Mass.
Fee',:-
` .. Lic. No:: �!;w.? .. : �. e ,,�;_.? , .......... .
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
✓IASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO GAS FITTING
or print) Date ,5
rH ANDOVER, MASSACHUSETTS
ons o 1% %//U/•0 A,1 S% J,rl,- Permit # Ir�a
/J Amount S
/7 5 O r✓ Owner's Name
Renovation11Replacement � Plans Submitted ❑
;; .. (Print or type) Check one: Certificate Installing Company
Name ll0 /l�� �pL 0.-1?� �' `l Corp.
i
Address �� SOX S%� ❑ Partner.
Business Telephone ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter /per
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked ves, please indicate the type coverage by checking the appropriate box.
Liability insurance policy E3Other tvpe of indemnity ❑ Bond ❑
Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter t42 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
i hereby certify that all of the details and information I have submitted (or entered) in above appiication are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas
Code and hapten 142 of the General Laws.
By:
Title
C ityi Tow n
JAPPROVED (OFFICE USE ONLY) I
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber 2� 33
❑ Gas Fitter License Number
Master
Joumeyman