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INSURANCE COVERAGE Check ne-,
have a current liability nsurpolicy r it"s substantial equivalent. Yes No
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Liability insurance ri0300�` Other type f'md,e rm its1:3 Band
Owner . sr . : I am aware that the licensee doesnot have the insurance coverage rewired by Chapter 14 2,of the
Mace. General Lama's, and that mysignature on this per'[Tat application waives this requirement.
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Signature of Owner or Owner's Agent Owner ED Agent 1:3
�,- i _ri do are tie andaccurate r �r certify that all t details ru information �� submitted (or entered) to the
best of my knowledge and that all plumbing work insu'I'llations performedunder, t Issued for this application will be in
compliance with all,perlinent provisions of the.Massachusetts State t Gas Corte and Chapter 142 of the General Laws.
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Insuran,ce Waiver- 1, the undersigned,have been inade aware tha,t the licensee of this `cation does not have any one oft.he above
three instirance
7'ignature Owner Agent
hereby certify that all of the details,a.11i ire orm ti 11 have Submitted(or entered),in above application are tnie and accurate to the
best of,my 1 led n that all plumbing work and installations per rr-lei underPerrmil Issued for this application will tie,in
complia-neeits all pertinent provistons,of the Massachusetts tat.e Plumbirig Code and Chapter 142 of the GeneralLaws.
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Name of Licensed Plumber-.
Insurance Cr irate the type.of insurance coverage by checking appropriatebox.
Liability insurance policy Other type of indenmity Bond
insurance surer: 11,the undersigned,have been made aware that the,licensee of this application, of not have any one olf the above
three insurance
r Owner Agent i-g-h
hereby certify that all of the details and infon-nation I have sub nutted, r entered) application are true andaccurate t
best of my knowledge, that all,plumbing work and installati, s perf ed under p t � for this application it i
i with C ter' ? the General ,..
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Type Plumbing License
title
City/Town LtCell'Se INUMDer Master Journeyman
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Own n .tr ant
I hereby certify that all the details and in onnati n have submitted r entered)in above application are tale and accurate to the
hest of my knowledge and that all plumbing work and installations performedunder Permit Issued for this application will he in
compliance wit s all pertinentMassachusetts State,Plumbing,Goes and Chapter 142 of the General aw .
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Signaure ot.171censeaur
Type of Plumbing.Liciei'ise
Title
City/Town, t o of er Mater Journeyman
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Date. .
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PERMIT FOR GAS, INSTALLATION
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has permission for gas installationa',., r
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in the build,ings of'
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IFORMAPPLICATON
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(Type ar print), Date
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Building Locations �° � �� Permit# e
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New Renovation
Replacement�t PlanSi Submitted
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h Partner.
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Name of Licensed Plumber r Ga FitterWFeNv\4 'VkC
INSURANCE COVERAGE Check one-
I have current li�,l ilit �r nc policy �r'It�� substantial equivalent. El
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pleaseIf you have checked ye
indicate the type coverage by checking the appropriate box..
Liability insurance policyEao'�' Other type f ire nri ity Bond E3
Owner"is ,'Insurance Weyer. I am aware that the,licensee does the Insurance coveragerequired by Chapter 142,of the
Mass. General Laws, and that my signattir n this permit application waives,this requirememt..
Chock on .
Si n t-uro of Owner or Owner's Agent Owner Agent El
t hereby certify that all of the details and infortn tion I have submitted or entered)in above application are true,and accurate to thie
best of nlyknowledge and that all plumbing work and installations, under Permit Issued for this i .tion wit' be in
Chapter 142�f"t�� ° li rz41 Laws.
ire with all pertinent provisions the Massachusetts StateState '� C ��
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Si nattir,of Licensed Plumber Or Gas Fitter
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Plumber 7
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APPROVED(OFFICIE USE ONLY)
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TOWN OF NORTH ANDO
PERMITFOR WIRING
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This certifies that
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wiring .. ebuilding of b 0..a a 0O'D P......ce.a. ..Ma;ww.....;.. a..w,..®...a-..a,
at
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'ELECTRICAL INSPECTOR {
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Check
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0ccupancy
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EICARD OF FIRE PREVENTIONI ` Rev. 1,19 (Ime blank)
=CTR1`CAL WORK,
APPLICATION FOR Pv0RMJT T P I Ell FORM ELE
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All � r t �r rm is c r J1 ` With the 12.00
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C i t v o,r T o w n o
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cring I? Yes Cli ff � 13 roprl t Boxy
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Utility 1 rig- tion, No. P �.��� o0ol
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re
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ni r,of'Feeders and , p elt
Loclat '� � l � r�, lWork*-,
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CU 111 lelt ila I 0 vin I lab Ile Ili Ia v bra Iva i ve C v 111 1[ C C1 0 r 0 ���`� � •
k No. or
No. or'Recuscd Fixtures
Hut Tubs, seer r'
No. or Lighting Outicts
Ab 0 vl c In- C1
kv 0
1*" 1 � ,.c] Units
No. of Lighting FI
,FIRE ALARMS IlNo.
No. of Receptacle Outlels
0. iand
No.orSiviRcliesNo.Of Gas Burners Dev I e
" N tallr x1
rTons
No.or Ranalesnid
ns 7D eic c lio 11
y��y9So
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C3, Other
,[No. or Dishwasher's
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..... B A it Security'� � M �
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find liar l le
it
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No. 1 eaterEl I lent
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Silo 11.5,
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0. o f 111,a 0,rj
o. 11entus
* r,o ni Bathtubs
OTHER
IN f desired. or az-rcqu;
M th wnei, no permit ,r ��� r Ors
ancmd r ,: � .
I.N S U R.�,,l C E C 0 N,*E jZ'l G E,- U n I css w.
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rcove,
ts substantial i at '� Iri ll
nclud � "' I � I t
the. 1 provides prooC liability r .
are .bites r - to the rmll �,uinlgl cMllce.
y
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CHECK � ��E. 1DZIc)
aired, municipall .
'Estimated'aloe of ElirliWork.
1
ai � t S tart: � 60,1
to be,r
t r *t EC 1 , and, r t r�
LlCm NO."
..,� L iN I E
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d el I P�w' �l��,➢�, ins,. I,y"iJ ,yw
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Lice-tiscee ` re
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applicable. ,. rt�.,. y ���-� �iouMla�� cm; �. �;'� ��P;-,I,MI,�' uu �. _ Al + IW� �n
m�,""' /�dP. "�.,�, _. m '^„ �� V �° 'r.Ar„r� 71ance 'M�r� �, ' �1lal �F %
�I N"�'y >�'� urn rar..� w,wmv ..* m . .,.�'rip W k�u 0 �
Addrus
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r r by 1 ��. 8 ' 11,1 � t xr 1
lo Nvl, I hcreby waivc this rcquircniCLjj(.
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