HomeMy WebLinkAboutMiscellaneous - 17 Molly Towne Road i 9 Me//yT ww Ro \
BUILDING FILE
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Senior Whole Health #
Tufts Health Plan Medicare Preferred
(Tufts Health Plan) #
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Medicare Card Number #
I give permission to bill my insurance coml
(Signature of person to receive vaccine or that per.
X
For Clinic/Office Use:
Vaccine name'\
Injection site: Date VIS given: _
JVaccine manufacturer: aVs
Name and title of vaccine administrator:
Clinic/office address:
r Influenza Forms—MAHP/Masspro Plan Reimbursement Program 2001
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACMUS�
ld* This certifies than . . l. . . . . . . . . . . . . . . . .
has permission to perform . ./1".e'.�..�ar��_. . `". . . . . . . . . . . . . . .
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plumbing in the buildings of ... . . . . . . . . . . . . . . .
at ,� 7. .,,`,rj.h.G.l rte. . !-- . .`�. . . ,_North Andover, Mass.
Fee/.) `1.1...Lic. No.
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J PLUMBING INSPECTOR
Check H L( G t
76011
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
_1 I f �+ Date
Building Location I`l 0 v `��Lj1JJ1J Owners Name P(110a Permit#
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Amount �/2•.
Type of Occupancy `(1k"11 1
New ® Renovation Replacement Plans Submitted Yes No ❑
FIXTURES
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(Print or type) Check one: Certificate
Installing Company Name Corp. �(p
Address Q-D- i2�0X l le I 0,(A Gu. �— SMA, Q E$c3 fo ❑ Pier.
Business Telephone 1. �� , GjL;� _ Firm/C&.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy ® Other type of indemnity ❑ Bond ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By:
SignaLure ol I-icenstKi rium0er
Type of Plumbing License
Title
City/Town +cense 114umoer Master ❑
Journeyman
APPROVED(OFFICE USE ONLY
Date./,)A;,l,e/ � . .. ... .
HORT1y
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TOWN OF NORTM ANDOVER
PERMIT, FOR GAS INSTALLATION
,SSACHUSE�
This certifies that .
has permission for gas installation . . ,f . l.(' G.a.:. . . . . . . . . . . .
in the buildings of . ... . . . . . . . . . . . . . . . . . . . .
at kw!'.4.(X. . . . . . . . . ... North Andover, Mass.
Fee.1.6.&"".--Lic. ... . . . . . . .
i AS INSPECTOW a
Check# U t)t
6267
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING
(Type or print)
Date ,i a � f a--•o"�
NORTH ANDOVER, MASSACHUSETTS
Building Locations 1-1 (\AOl l� ►;,� �ZiC Z 6,t
Permit#
Amount$ �oG�
Owner's Name t C.�►v��
New® Renovation Replacement Plans Submitted
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� SUB-BASEMENT
BASEM ENT
1ST. FLOOR f
2ND. FLOOR
3RD . FLOOR i 1
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
(Print or type) Check one: Certificate Installing Company
Name OVA C-1 'T -T>�C,E� �vv(, ® Corp. P_14�C) _
Address `P 2>c,?,:! 1 I Partner.
Business Telephone Firm/Co.
Name of Licensed Plumber'or Gas Fitter (� �
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INSURANCE COVERAGE Check one:
I have a current liability Insurance,policy or it's substantial equivalent. Yes M No 13
If you have checked yes,please indicate the type coverage by checking the appropriate box.
Liability insurance policy iP] Other type of indemnity D Bond 0
Owner's 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:
Signature of Owner or Owner's Agent Owner13 Agent
hereby certify that all of the details and information I have submitted(or entered)in 13
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 Gas Code and Chapter 142 of the General Laws.
By: Signature of Licensed Plumber Or Gas Fitter
Title ® Plumber
City/Town, Gas Fitter License Number
Master
_ APPROVED(OFFICE USE ONLY) Journeyman