HomeMy WebLinkAboutMiscellaneous - Exception (80)-L0. .
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DC` no ""�"'^
(Print or Type)
Building Location
Mass
Date 19 Permit# -3.1
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CYoj�r/L�
Owner's Name /#—e1
New D Renovation 1:1 Replacement
FEATURES
11,150
Type of Occupancy -
Plans Submitted Yes ❑ No L_/
Installing Company Name_ !% moi•W-s�� Check one: Certificate
Address S/ /iiyP� /eFJ Corporation
17 Partnership
Business Telephone- Y 7lg $�i� ���1 Lim/co. ^
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a current li 'lity insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142.
Yes current
❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy df--� Other type of indemnity 1-1 Bond 0
OWNERS INSURANCE 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:
Slrtnature of Owner or Owner's Aaent — Ow 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 installs' med under the permit issued for this application will
be in compliance with all pertinent provisions of the Massac efts P ing de and Chapter 142 of the General Laws.
By
,gna ure o License,
er
Title Type of License: Master/ Journeyman O
CltyrTown License Number__ 114 -//Z�
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SUB-BSMT.
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BASEMENT
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1ST �FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
-
Installing Company Name_ !% moi•W-s�� Check one: Certificate
Address S/ /iiyP� /eFJ Corporation
17 Partnership
Business Telephone- Y 7lg $�i� ���1 Lim/co. ^
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a current li 'lity insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142.
Yes current
❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy df--� Other type of indemnity 1-1 Bond 0
OWNERS INSURANCE 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:
Slrtnature of Owner or Owner's Aaent — Ow 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 installs' med under the permit issued for this application will
be in compliance with all pertinent provisions of the Massac efts P ing de and Chapter 142 of the General Laws.
By
,gna ure o License,
er
Title Type of License: Master/ Journeyman O
CltyrTown License Number__ 114 -//Z�
APPROVFr) OFFICT USF ONI.Y)
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Date ? ?Y. .
3652 / ///
O NORTH
"c TOWN OF NORTH ANDOVER
OL
PERMIT FOR PLUMBING
This certifies that .../91 .e r ....................
has permission to perform .... ...........................
plumbing in the buildings of ..(, q.q. .......... .. .. .
at. -2')... 1�, 1�r. t�... F ......... orth Andover, Mass.
Fee.,...v:'...Lic. No.. J. .... ... i
PLUMBING INS ECTOR
03/25/98 10:58
WHITE: Applicant
20.00 PAID
CANARY: Building Dept. PINK: Treasurer