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TOWN OF NORTH ANDOVER
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PERMIT FOR GAS INSTALLATION
This certifies that . i2......................... .
has permission for gas installation ..l f 1. -�- ..........
in the buildi gs of ... � ... � ......... t`...... .
at ...... , North Andover, Mass.
Fee:, --2. �./�'VLic. No. .. ! . ..........................
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XGASINSPECTOR
'-Check
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4817
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MASSACHUSETTS UNIFORM APPUCATON
(Type or print)
NORTH ANDOVER, M
Building Locations
Owner's Name
New ❑ Renovation Replacement 11
FO PEP2vff TO DO GAS G
Date �' ot4
Permit #
Amount $
Plans Submitted
Firm/Co.
e,
Name of Licensed Plumber or Gas Fitter f
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 11 No
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 1 Other type of indemnity D Bond
14
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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 re gement.
Signature of Owner or Owner's Agent
i hereby certify that all of the details and information I have
best of my knowledge and that all plumbing work and instal
compliance with all pertinent provisions of the Massachuseti
Bred) in above application are true and accurate to the
under Permit Issued for this application will be in
and Chapter 142 of the General Laws.
SignatuWof Licensed Plumber Or Gas Fitter
Plumber /3 y 13
Gas Fitter icense iNumoer
ri-Oaster
Joumeyman
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SUB -BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
Efi
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type) hec o Certificate Installing Company
9
Name e
LT—Corp.
Address �� S Jj, E] Partner.
Firm/Co.
e,
Name of Licensed Plumber or Gas Fitter f
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 11 No
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 1 Other type of indemnity D Bond
14
^ w
i
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 re gement.
Signature of Owner or Owner's Agent
i hereby certify that all of the details and information I have
best of my knowledge and that all plumbing work and instal
compliance with all pertinent provisions of the Massachuseti
Bred) in above application are true and accurate to the
under Permit Issued for this application will be in
and Chapter 142 of the General Laws.
SignatuWof Licensed Plumber Or Gas Fitter
Plumber /3 y 13
Gas Fitter icense iNumoer
ri-Oaster
Joumeyman