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Print of Type) r UNWUHM APPLICATION FOR PERMIT TO DO GAS-FITTINQ
NORTH ANDOVER _� 5
_ , Maas. Date t g 4 6
Building
Location �� � c�=b� 1!f Permit # 2 3 d `
Owner's
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Name
New Renovation ❑ ReplacemerA fl Plans Submitted:. Yes ❑ No
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2118-112MT.
S/lIR MINT
1STFLOOR
Mae
2N0.FLOOR l
3RD FLOOR
4TH Moon
STH FLOOR
GTH FLOOR
7TH FLOOR t
!TH FLOOREB
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Check One: Certificate
instal)tng Company Name +�S \&C P-d0rp
Address - V,0 . &k �U1
[� Partnership
❑ Firm/Co.
Business Telephone_',... .. 7 Y'l7�oj
Name-of Licensed Plumber or Das Fitter -S—) >• c -4P
INSURANCE COVERAGE: Check on
-I have a current Ilablllty Insurance policy or its substantial equivalent. ' Yes f No ❑
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
,•A liablI ty Insurance policy � Other type of Indemnity O Bond ❑
OWNER'S INSURANCE WAIVER: 1 sm 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 permlt application waives this requirement.
Check one:
'Slgnature of Owner or Ovme
Owner ❑ Agent ❑
I hereby certify that all of the detalls and Information I have submitted (of entered)In above application are true and accurate to the best of my
knowledge and that an plumbing work and Installations rformed under the permH Issued for this appikatlon will be In compIlance with all
pertinent provisions of the Massachusetts State Gas(code and Chapter 112 of the al La
�' TCumber
nse:
Title na urs o nae um et or aserer <.:
Master tkense Number
CttylTorvn Journeyman
AFMOVED.(OFFICE USE ONLY)
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�.Tn Date A9 72306 �j.C. . ... .
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HpRTN , TOWN OF NORTH ANDOVER
�? PERMIT FOR GAS INSTALLATION
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This certifies that . . .Cr.A //,!t. %. . . . . . . . . . . . . .
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has permission for gas installation . . . N o
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in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . .
at . . .i.y. . .(--P? `� 0. ?. . . . . . . . . , N rth Andover, Mass.
F Fee. . . . . . Lic. No../. a 2.'!A' � . . . . . .
GAS INSPECTOR " a
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File