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210/095-A-0114"0000.0 - - ---
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING t
(Print or Type)
NORTH ANDOVER Mass. Date
kuilding Location Permit
Owners Name ��?�rSZA,�
' New -7 Renovation Replacement p Plans Submitted D
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SUR—BS MT. �
BASEMENT
1ST FLOOR
2ND FLOOR
3110 FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
(Print or Type) / Check one: Certificate
Installing Company Name �j L-O �orp. V�'7?6
Address ,j1-11" A � IV- Partner.
Firm/Co.
Business Telephone: Tcf-
Name of Licensed Plumber or Gas Fitter
Insurance Coverage: Indicate e type of insurance cov rage by checking the
appropriate box:
Liability insurance policy Other type of indemnity Q Bond
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 coverages.
Signature of owner/agent of property Owner 17 Agent M
1 hereby certify that all of the details and information 1 have submitted (or entered)in above application are true and accurate to the best of my
knowledge and that all plumbing wort and installations perfomtcd under'Permit isseed for this application will be in eompiiance with all pertinent
provisions of tho Massachusetts State Gas Code and Chapter 142 of the General Laws.
TYPE LICENSE:
By Plumber � -// l
Title G fitter ignatu' re Licensed
Cit y/Town: .aster Plumber or Gasfitter
Journeyman !&'/'o,'7
APPROVED (OFFICE USE ONLY) _ Lici-ansiLf Number
` Date.... .. ....... .. ........
B 7 7 ,
ppRTp TOWN OF NORTH ANDOVER
Of...... .6'6
3:
p PERMIT FOR GAS INSTALLATION
.. F
r o s
�9SSACHUS�t
This certifies that . . . . . . . . . . . . �. ... . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation .. . . . . . ... . . . . . . . . . . . . . . . . . .
in the buildings of . . . . . . . . . . . .I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at .: :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., North Andover, Mass.
Fee. . . . . . . . Lic. No.. . . . . . . . . . . . . .". . .. . . . . . . . . . . . . . . .
GAS INSPECTOR
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File
12/08/94 08:44 15.00 PAID
0.4 NORTH
4t'i°ye1NO
3? OL
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w
NORTH ANDOVER BUILDING DEPARTMENT
*�q'e,,,.o•�1 * 400 Osgood Street
ss�caust
TeL 978-688-9545
Fax: 978-688-9542
BUSINESS FORM FOR TOWN CLERK
DATE:
NAME: t z_-
ADDRESS:
ZONING DISTRICT:
`/A 4
TYPE OF BUSINESS:
BUILDING LAYOUT PROVIDED: YES NO
AVAILABLE PARKING SPACES:
ZONING BY LAW USAGE: YES NO
C
BUILDING INSPECTOR SIGNATURE
f .�V C9J 0--)i
Revised 11.5.04
BUSINFSSFORM FOR TOWN CLERK L/�1 f�(J 'til^ '�•e2 �� � /- l�/�(�( C��c l� � ��c
Date.. I
,NORTH
TOWN OF NORTH ANDOVER
p F
PERMIT FOR GAS INSTALLATION
h
�9SSAC
.5E�<
This certifies that . �'4'`t Ct S'. 7. . . . S . . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . .F . . . . . . . . . . . .
in the buildings of . yA 2 A S7 t
at . . i �.`i . . . . Y v,`.1.1. .1. . . . . . . . _., North ndover, ass.
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Fee. .'3�. . . Lic. No. 6 . . . �: ����? f. A: . . . . . . .
GASINSPEC OR
Check# a D s -Q.
4230
MASSACHUSETTS UNIFORM APPLICATON FOR PERNIIT TO DO GAS FITTING
\1
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
Building Locations f �� (� Permit#
Jp� `7 l Amount$
4 4J Owner's Name
New Renovation Replacement n Plans Submitted
a o 3 a3 12 ° ° �' 0 o°, H 01
SUB-BASEMENT
BASEMENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
STH. FLOOR
6TH. FLOOR
7TH. FLOOR
STH . FLOOR
(Print or type) ,/� / , , - f 1' one: Certificate Installing Company
Namer�-!' (/CJ /�. X2%2�.5 V Corp.
Address v v ' Partner.
Business Telephone Firm/C0.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ Bond ❑
A
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 Owner ❑ Agent ❑
t hereby certify that all of the details and information I have submitted(or entered)in above application are true and urate to the
best of my knowledge and that all plumbing work and installatio performed under Permit Issued for this applica' will be
compliance with all pertinent provisions of the Massachusetts S as Code apter 142 of the General
i
By: ignature of Licensed Plumber Or Gas Fitter
Title Plumber
City/Town Gas Fitter Icense Number
Master
APPROVED(OFFICE USE ONLY) ❑ Journeyman