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HomeMy WebLinkAboutMiscellaneous - 93 ROCKY BROOK ROAD 4/30/2018 (26)MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print of Type) NORTH ANDOVER, . Mata. Date U _to 1 Butlding� �L /�PermM rtLocation 0 Cr /�12 d dF Owner's —•! ' L; Name 0. 1.1 New p-'-- Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No. p- ` . - _ Check one: Installing Company NameZ—.-2❑Cori.. Address L Z) n0 ;Y l✓ AL d S-1 %r ❑ Partnership Business Telephone �9 - d ZD Name of Ucensed Plumber ys Jf Cartllicate - INSURANCE COVERAGE: Checx one 1 have a current IIabIRy Insurance policy or Its substantial equMalent Yes ©'-- . No ❑ It you have checked yn, please Indicate the type coverage by checking the appropriate box. A IlabiRy insurance policy l3� Other type of ktdemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the ilcenaee does not have the Insurance coverage required by Chapter 142 of the Mass. General laws, and that my signature on thla permit application waives this requirement. Check one: Sign- sture ol Owner of Owner g Owner, ❑ Agent ❑ oral - I hereby ceftlty that aA of the doting and Information 1 have eubmM d tot enteral In tlon are true and accurate to the gest of my Inowfedpe and that as Clumbinq work and instaAaUona pKdormed under the � pertinent provisions of the Massachusetts State Plumb4rq Code sad Chaptw 142 of a i}on wti7 h rad with all BY r • of Lkahsod Pkmnow Title Gty/Town , Ucanse Number Type of Plumbing IJcense: Master A!'F OVf0 (OFF10E USE ONLY)' Jowneyman 0 ai » s w i W < » M i M <! < ~ a O a M i e. a M y M M=. t P N S a < w • _ : _ s. V ar Lis A X 16 Y M• O La • f' a1�L 1- ri i M s l a p el -- t P p a t> >C o Y w o o i s ua-s a mi. aAaaYtNT IST FLOOR IND FLOOR 3110 FLOOR 4TH FLOOR I ITN FLOOR STM FLOOR. TTN FLOOR aTHFL00R - - _ Check one: Installing Company NameZ—.-2❑Cori.. Address L Z) n0 ;Y l✓ AL d S-1 %r ❑ Partnership Business Telephone �9 - d ZD Name of Ucensed Plumber ys Jf Cartllicate - INSURANCE COVERAGE: Checx one 1 have a current IIabIRy Insurance policy or Its substantial equMalent Yes ©'-- . No ❑ It you have checked yn, please Indicate the type coverage by checking the appropriate box. A IlabiRy insurance policy l3� Other type of ktdemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the ilcenaee does not have the Insurance coverage required by Chapter 142 of the Mass. General laws, and that my signature on thla permit application waives this requirement. Check one: Sign- sture ol Owner of Owner g Owner, ❑ Agent ❑ oral - I hereby ceftlty that aA of the doting and Information 1 have eubmM d tot enteral In tlon are true and accurate to the gest of my Inowfedpe and that as Clumbinq work and instaAaUona pKdormed under the � pertinent provisions of the Massachusetts State Plumb4rq Code sad Chaptw 142 of a i}on wti7 h rad with all BY r • of Lkahsod Pkmnow Title Gty/Town , Ucanse Number Type of Plumbing IJcense: Master A!'F OVf0 (OFF10E USE ONLY)' Jowneyman 0