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9497
04.
Date...7/? z�
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
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This certifies that ......................
has permission to perform ......
plumbing in the buildings of Alkzq. . Alaerlf;f ..........
at . -,,�v . .&/rj/ - - - Mass.
Fee. . Lic. No.,16.!F;7 �42
Check# Z11 -z.3
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK'
CITY MA DATE ?A/ 's PERMIT#
JOBSITE ADDRESS 491 , y,,/ c,,,1 a, OWNERS NAME A119Cd
j
OWNERADDRESS TEL --)d 5 - '-n- q:z 9('
OCCUPANCYTYPE COMM . ERCIAL Z�_� EDUCATIONAL -RESIDENTIAL
NEW: [I RENOVATION: REPLACEMENT: [I PLANS SUBMITTED: YES NO El
FIXTURES I FLOOR— BSM 1 2 3 4 5 6 7 8 9.1 10 11 1213 14
BATHTUB
CROSS CONNECTION DERE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM 7_7
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA D(RAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability nsurance policy or Its substanda[equivalent which meets the requirements of MGL Ch. 142. YES Me_`NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 90", OTHER TYPE OF INDEMNITY BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not h the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that m y signature on this permit app9cation Mh�e_s *Is. requirp-Ttent.
CHECK ONE ONLY: OWNER[-] AGENT[]
SIGNATURE OF OWNER OR AGENT
I hereby ce" that all of the details and Information I have submitted or entered regarding this applir� are true and accurate to the best of my knowled , ge
and that all plumbing work and Installations-pedbrmed under the permit Issued for this applicat! will bo—ein-&nzkiiancewith-VTeronent vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME paniel Huntress LICENSE# 1 0977.�_ URE
'00'
MID JP 10977 CORPORATION M 2 5 4 9 PARTNERSHIP # [C
Roto -
COMPANY NAME Nurotocoof ma d/b/a Ronter—ADDRESS 175 Mar)le Street
CITY Stoughton STATE MA ZIP .02072 TEL781 -2c)7_7049
FAX 7§1 -341-8817 CELL781 -603-5412 EMAIL dan. huntress@rrsc. com
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V/0
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wjmw VJ Inve3aganons,
NEEMBEEE& 600 Washington &reet
Bvmi4 MA 02111
www-wasseovIdia
Workers9Comp
ens3tiOn Insurance Affidavit: Builders/Contractors/Elect
DID11001 Infonnation riclawRiumbers
iame
ity/statemp:' Stoughton mA, 02072 Phone#: 781-297-7049
V you an cU1P10Ycr?.Ch0A the. -appropriate box.-
V'I am a emPloyer with. . 4. 1 SM -S gencral contractor nd I
employees 0A and/or parf-thm).
3 1 am a sole proprietor or
lave bired ft sub-couiracka
NsW
parftw.
abip and have no employees
on the aMdwd shea t
These sub-contracim have
Morkiqg for.M'e in any capacity.
[No wOrken, pomp. insurance
workast cov. insuranot
5.0 We are a corporation and its
requirefl
I arn a homeowna doiAg
offun have nercised Mw
all work
nWSCK [NO wodm'comp.
rq*ofexenvdmpermGL
-C. 15Z f 1(41 and wit have: no
UVIOYM. (No
M*surznM raphVd.]
Vpbmqt thd chub bu 0 1 sho fM 00 64
wowun V*0 MUMIM. —
WWm bdww —&av&g 6* wQtC=. CMMFCEU&u
Type of Project (required):
6- 13 New 1 flubliction
7. Oltanodelig.
.9.
10-13 Lllectdcd ROM C -W additloas
Pliftft Jrcp,
Roof repaim a ' 5 or� addid=
13.[], Mer
—0=90 Mdft&wM&Md9ftWw
McbIN GM C.beck #6 tm noo anwhed M tMfimd Ibnt &min& 9w wM Cut"Contacknir
M"
Ofdw subec . UftftM end otek weemn- am* VCHOY hfornaldm
an employer ow is Providing workers J'
00MFMa*n'bUwwncef#rm
YeMPIWOM.
Y#0rSdf-iAs-Lic-#: wc- 7
43 2.M-07. EM*Rdm Date:
'iteAddress:
th a CoPY Of the workers9 COMPeusatJOR Policy declaration
page (showing
re to 8 the Policy nuu*er and 00MUba daft).
e*M ccvcmge as required tmder SeW'on 25A ofMGL c. IS2 lad 10 the fiqMition of -
IP tO $1,500-00 andlbr oneyew fivrisoment as wen as civil p - can crimbW penalties ofa
to $2SO-00 a dq spbg.tke violztDi. cuiltici in die form ofa STOP WORK ORDER and a fine
Be advised 69 a copy of this statement
tigatio= offlie, DIA for insurance covemp vaif=tioL VAO bc ftWarded lo dw Orace of
*"gvy univer rise pahn andpenelda qfperjapy
that the Informaden Provad above is &M Md correm
Flowaseonly. Donof write I. 'hisdrea, to be COMPIdedbyeifyor town offlelffL
ty or Tmm:
PernfiVUcense #
Wng Anacrity (drde one):
302rd Of Health L Building Department 3. C[tY/rQvm Clerk 4. FiectrIcal
Mer Iftipector 5. Plumbing Inspector
11tactPenon: Phone 0: