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Date. o2 / 7 o,5
TOWN OF NORTH ANDOVER
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. � PERMIT FOR PLUMBING
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This certifies that ... �. (.Y.."`.. .. .......C...... .
has permission to perform ... j /'
plumbing in the buildings of ./.�..-.1..,:}�. ��..'... .
F- : , North Andover, Mass.
Fee._ .- ULic. NOA W ..............................
N ) PLUMBING INSPECTOR
Check # /
6341
MASSACHUSETTS UNIFORM
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building
fi,
'ATION FOR PERMIT TO DO PLUMBING
Z' ' - S �-
Date
G u-`Ptpi Permit#
Amount
New 15 Renovation 1:1 ReplaVent 1:1 Plans Submitted Yes 11
FIXTURES
No ❑
(Print or type)✓ ��J �� / Check one: Certificate
Installing Company Name ✓ / " C l
r ❑Corp.
Address ElPartner.
usmess Telephone
Name of Licensed Plumber:
Insurance Coverage: Indicate the t e of insurance coverage by checking the appropriate box:
t Liability insurance policy r7V Other type of indemnity ❑ Bond
La
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 pe ed and Pe 't Issued for this application will be in
compliance with all pertinent provisions of the Massach is at ing Chag&er 142 --of the General Laws.
By:
f
OVED (OFFICE USE ONLY
22 Type of Plumbing License
3�
dense um er Master ❑ Journeyman