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Try TOWN OF NORTH ANDOVER
Of ��ao �n 1ti0
=; �_ �.� Op PERMIT FOR GAS INSTALLATION
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I This certifies that . . . . .:.' .,. . . .+. . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . . :... .'. . . . .. . . . . . . .
in the buildings of .r,:. . . ', � . . . . . . . . . .. . . . . .
at—
. . . . .. . . . ..,. . . 1. . . . },,r . . , North Andover, Mass.
Fee, %. .1 . - Lic.
. . . . . . . . . . . . . . . . . . . . . . . . . .
r GAS INSPECTOR
WHITE:Applicant CANARY:Building Ddpt. PINK:Treasurer GOLD:File
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING/ ,�
(Print or Type)
NORTH ANDOVER Mass. Date .S'' 3 A�-/
building Location L o-r �� �-¢r�/�� �'j_�,P+ Permit # Ai. 7o
.� Owners Name I't'(QeM fAPb Ay ,'IIJ�' ism
i
• New Renovation Replacement Plans Submitted
F I X T U R E S
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BASEMENT
ISTFLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
TTK FLOOR
8TH FLOOR
(Print or Type) Check one: Certificate
Installing Company Name (()gel /4 Tact Pdfy C' Q Corp.
Address- 19-16 4AT`772e jg�/D Igf I/coq fV = Partner.
rr Firm/Co.
f
Business Telephone: -T�SA
Name of Licensed Plumber or Gas Fitter (I-) c i f fAt-(
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy C�j Other type of indemnity 0 Bond Ej
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 0
1 hereby certify that all of the dctails and information 1 have submitted (or entered)in above application are true and accurate to the test of my
knowledge and that all plumbing work and WEAdations performed under Permit issued for this application will be in compliance with all pertinent
provisions of tho hfassachusetts State Cas C ude and chapter 142 of tho General Laws.
B TYPE LICENSE:
By Plumber
Title Gasfitter S 10 ignature of Licensed
City/Town: Master Plumber or Gasfitter
Journeyman
APPROVED (OFFICE USE ONLY) License NU ber