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A4SSACHliSE"M LNUORNI APPUCATON FOR PERTNIrr TO DO GAS FMING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations ld Z /4
Owner's Name
New ❑ Renovation
Replacement Plans Submitted
Date - 7- ielei
Permit # 2) <�
Amount $ p
(Print or type)_ Check one: Certificate Installing Company
Name 4!51,/—:4 G¢ %�� a, `%7Z El
Corp.
Partner..
Firm/Co.
Name of Licensed Plumber or Gas Fitterepi %
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes M Non
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policyOther type of indemnity Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. Cyeaws, ant at m siaturc on this permit application waives this requirement.
f ! Check one:
Signature of Owner or Owner's Agent Owner 0 Agent
I K;LUUy UU,L,ly rear rill ui rile uu.aus anu intormanon i nave Summitteu (or entered) in above application are true and accurate to the,
hest of mm 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 VlassachusesttS State: Gas Code and Chapter 112 of the General Laws.
By:
Title
City/Town
:APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plunnbcr l:5 -41e I-
M Gas Fitter tense IN um er
ter
Jooururneyman
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SUB -BASEMENT
BASEMENT
1ST. FLOOR
2N D. FLOOR
3RD. FLOOR .
4T1I. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type)_ Check one: Certificate Installing Company
Name 4!51,/—:4 G¢ %�� a, `%7Z El
Corp.
Partner..
Firm/Co.
Name of Licensed Plumber or Gas Fitterepi %
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes M Non
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policyOther type of indemnity Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. Cyeaws, ant at m siaturc on this permit application waives this requirement.
f ! Check one:
Signature of Owner or Owner's Agent Owner 0 Agent
I K;LUUy UU,L,ly rear rill ui rile uu.aus anu intormanon i nave Summitteu (or entered) in above application are true and accurate to the,
hest of mm 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 VlassachusesttS State: Gas Code and Chapter 112 of the General Laws.
By:
Title
City/Town
:APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plunnbcr l:5 -41e I-
M Gas Fitter tense IN um er
ter
Jooururneyman
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