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This certifies that
has permission to perform
Fee'. Lic. No.
Check .N
yvl�7
6499
Date. .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
/CIT/L�
�PiZ
7�'....
1.
, Mass.
NIAbbACH,USETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING v J
(Print or T pe)
Mass. Date
Per i #
Building location
er' M. P.
Type of Oc upancy •
New ❑ Renovation 0 Replacement
Plans Submitted: Yes ❑ No ❑
F�x RES
B.P. #
SUB-BSMT
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6THOOLFR
7TH LF 0 RO
Installing Company Name
4d d ress lS �Aii►r n A
3usiness Telephone
SEWER #
SEPTIC # .
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Check bne: Certificate
P Corporation
�
lame of Licensed Plumber or Gas Fitter
I AI Q I 10 A u n1 r+.....:._
❑ Partnership
'CT Firm/Co.
I have a current liability insurance policy or Its substantial equivalent, which meets
Yes
� No the requirements of MGI -Ch. 142.
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l
If y6�141o have checkedes, please indicate the type of coverage by checking the appropriate box.
A liability Inspolicy P Y� Other type of indemnity ❑ Bond ❑
OWNER'S INSURNACE 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.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent ❑
ereby certify that all of the details and information I have submitted (or entered) In above application are true and accurate to
knowledge and that all plumbing work and installations performed u r the permit Issued for thi a plication will be in compliance with
pertinent provisions of the Massachusetts State Plumbing Code and h to 42 of e G oral Law the best of
By
Title Sign re of Licensed Plum Er
C
Ityrrrt.wn
APPROVED (OFFICE USE ONLY) Type of Licenser QAltfster
� DJourneyma:n
,� License Number_ 3 '
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