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Date.....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...........................................
has permission for gas installation ............................
in the buildings of ..........................................
at .................................... North Andover, Mass.
Fee......... Lic. No........... ..........................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) t
l NORTH ANDOVER Mass. Date :6
I /J
iguilding Location � 9 DID L'A-(�-t- Permit # / aS &3/ L13
.� Owners Name146-fr� U , 4P-
• Y New novation D Replacement Plans Submitted D
lT
(Print oType)
Installing
Check one: Certificate
Lvftk(�� Corp.
Company Name
Addressl�pt��J`U�L -
Partner.
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Firm/Co.
Business Telephone: �03 _ Z9-
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Name Gas Fitter
_
of Licensed Plumber or
�✓�C
Insurance Coverage: Indicatethe t pe of insurance coverage 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.
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6TH FLOOR
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(Print oType)
Installing
Check one: Certificate
Lvftk(�� Corp.
Company Name
Addressl�pt��J`U�L -
Partner.
r -n
r� R C)1)2
Firm/Co.
Business Telephone: �03 _ Z9-
'� -3
Name Gas Fitter
_
of Licensed Plumber or
�✓�C
Insurance Coverage: Indicatethe t pe of insurance coverage 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 0
I hereby certify that all of the deuihs and information 1 have submitted (Cr entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under Permit iutmd to: this application will -be Ln compliance with all perttn=t
provisions of tho Massachusetts State Gas Code and Ciupter 14: of the General haws.
By TYPE LICENSE:
Plumber
Title Gasfitter Signature of Licensed
City/Town: Master Plumber or Gasfitter
Journeyman OZ9KC
APPROVED (OFFICE USE ONLY) — License Number
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