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1� u"WuHtA APPLICATION FOR PERMIT TO DO t3ASFITTINQ
(Print of Type)
NORTH ANDOVER , Mass. Date 5
1946
Building
Location Permit
Owner's n ::
Name
New Renovation ❑ Replacement ❑ Plans Submitted:. Yes C1 No
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1aTFLOOR
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3AOFLOOR
4TH FLOOR
STH FLOOR
1 4TH FLOOR i
7TH FLOOR t
4TH FLOOR
/1 Check one: Certificate
InstanIng Company Name \&C
Address
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:•� . �:.�( d Partnership
❑ Firm/Co. -
Business Telephonej 7 tt/y 7 sD j
Name of Licensed Plumber or Gas Fitter_ -S 7>`t--P— G Lt2 -
rINSURANCE COVERAGE: Check on
I have n current liability Insurance policy or its substantial equivalent. ' Yes [ No ❑
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
'A Ilabli ty Insurance policy Other 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. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner of Owner's ens Owner 0 Agent C1
1 hereby certify that all of the detalls and Information I have submitted for entered)In above application efa true and accurate to the best of my
knowledge and that an plumbing work and Instaliattons performed under the permit Issued for this application will be In compiience with all
pertinent provisions of the Massachusetts State Das Code and Chapter i42 of the al la
T nse:
umber na ura o sem nuer or as rarer
Tile tar
Master License Plumber
'CttyJ7ovm ❑Joumeyman
llF'ITV ED (OrFiCE USE ONLY)
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,,oeTH TOWN OF NORTH ANDOVER
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4 0? "� �� PERMIT FOR GAS INSTALLATION 1
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This certifies that . . {.� . . . . . . . . . . . . . . .
has permission for gas installation . . . . HA u^. e-. . . .
in the buildings of . . . , , , , , , ,�'
at .�l l✓ . .F°'?� lti G . . . . . . . . . Andover, Masi
Fee. � �?c:�. . Lic. Noj P . . . . . .
GAS INSPECTOR �
WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD:File j