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Date ...... ... � .� .... .
TOWN OF NORTH ANDOVER
A PERMIT FOR GAS INSTALLATION
This certifies that .... ; .......... �...................... .
has permission for gas installation ... .............
in the buildings of ...... r.... ..................... .
at. ........... North Andover, Mass.
Fee. t ���.. tic. No.- , r y1 ... ..........................
GAS INSPECTOR
WHITE: ApplilieertT —CANARY: Building Dept. PINK: Treasurer GOLD: File
����-��`•`MASSACHUSETI"SLUNIFORM APPLICATION FO
(Print TO D�O�QASFITTINq w
(Print or Type) <
NORTH ANDOVER , Maas. Date 2- 3 tgCy1--
Building Z
Location V Permit #
Owner's
Name
New ❑ Renovation ❑ Replacement (a Plans Submitted: Yes ❑ No [p
aue�—asMT.
MASEMENT
1ST FLOOR
IND. FLOOR
'RD FLOOR
4tH FLOOR
STH FLOOR
0TH FLOOR
7TH FLOOR
ATH FLOOR
�7- Check one: Certificate
Installing Company Name , 1 r � � �� .
Address S`v 0 Qy r01141 Q Corp.
TA A t 4 `/ J elleL� ( d Partnership
�y < 0-6,m/Co.
Business Telephone (e f —Lill,
Name of Licensed Plumber or Gas Fitter — 120 6 e,4 .q-
INSURANCE
qINSURANCE COVERAGE: Check orrp
I have a current liability Insurance policy or Ms substantial equivalent. Yes No No p
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability Insurance polis p' ;
Y Other type of Indemnity ❑ Bond O
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:
%nature of tAvner or Owner's Ment Owner ❑ Agent ❑
I hereby certify that all of the details and Information 1 have submitted (or entered) In above application are true and accurate to the best of my
knowtedpa and that all plumbing work and Installations performed under the permit Issued for this appl tion II be In compliance with all
pertinent provbions of the Massachusetts State Gas Gbde a d Ch of
I apler ICe the7ura wa
T lken -
HNumho
stiller
nse um or or as Filler
WrMaster License Numberl4 �3
DJoumeyman __
APPF"VEO (OFFICE USE ONLY)
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�7- Check one: Certificate
Installing Company Name , 1 r � � �� .
Address S`v 0 Qy r01141 Q Corp.
TA A t 4 `/ J elleL� ( d Partnership
�y < 0-6,m/Co.
Business Telephone (e f —Lill,
Name of Licensed Plumber or Gas Fitter — 120 6 e,4 .q-
INSURANCE
qINSURANCE COVERAGE: Check orrp
I have a current liability Insurance policy or Ms substantial equivalent. Yes No No p
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability Insurance polis p' ;
Y Other type of Indemnity ❑ Bond O
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:
%nature of tAvner or Owner's Ment Owner ❑ Agent ❑
I hereby certify that all of the details and Information 1 have submitted (or entered) In above application are true and accurate to the best of my
knowtedpa and that all plumbing work and Installations performed under the permit Issued for this appl tion II be In compliance with all
pertinent provbions of the Massachusetts State Gas Gbde a d Ch of
I apler ICe the7ura wa
T lken -
HNumho
stiller
nse um or or as Filler
WrMaster License Numberl4 �3
DJoumeyman __
APPF"VEO (OFFICE USE ONLY)
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Date.;!/:7. .. .......
02 '` TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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This certifies that .... :. .. S t`? . .� `.. ...................
has permission for gas installation .... .............
in the buildings of ... ..!`.... ............................... .
at ..'.t. ....... , North Andover, Mass.
Fee ..Lic. No... �...-^-�'?� :..... .
XGS INSPECTOR
Check #
5666
MASSACHUSEIZS
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations ,U V�--
P ATON FOR PERAW TO DO GAS FPITING
Date e -117A
< Permit #
Amount $ ,ale
)wner's Name
New ❑ Renovation ❑ Repla a
ent Plans Submitted ❑
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SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
STH. FLOOR
(Print or type) ` % f / Che one: Certificate Installing Company
Name `tel ��fLe �l� /' Corp.
Address 5 s ky rZ ❑ Partner.
Business Tele one ❑'pirm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ — No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy M- 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 or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and lntormatnon i nave suormueu kUi euLe►euj .l, auvvc at,Y.,. "LIV..
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massacfh sett StatepGa Code an�i Chapter l4b of the GPeral Laws.
[APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
[3_ Plumbery %�,
❑ Gas Fitter License Number
Master
❑ Journeyman