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Date.....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...... I ....... .................
has permission for gas installation k ........... ............
in the buildings of ... ............. .........................
at
North Andover, Mass.
Fee. Lic. No.. . ..........................
GASINSPECTOR
Check # � . (/
r '7
37 -, i
MASSACHUSETTS UNIMRM APPUCATON FORPERNUr TO DO GAS FflTNG
(rype or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations C96 /) �- — Permit #
4�11y&r k�y� Owner's Name AAele� Amount $
New 1:1 Renovation [:] Replacement [:] Plans Submitted [:]
(Print or type)
Name of Licensed Plumber or Gas Fitter
one: Certificate Installing Company
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes [:] Noo
Ifyou have checked M, please indicate the type coverage by checking the appropriate box.
Liability insurance policy IQ Other type of indemnity 11 Bond El
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
A
i nereoy certay mat an or me ctetans and intormation I nave submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perfl , ed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State ode and Chaptqrj 142 of the General Laws.
City/Tov=—�
(OFFICE USE ONLY)
Signature of Licensed Plumber Or 6as Fit -ter
L
Plumber a _7 7
Gas Fitter License Number
Master
0 0 Mym
an
Date e� "-, /
N2 4
It
TOWN OF NORTH ANDOVER
0
PERMIT FOR PLUMBING
This certifies that P
has permission to perform ..... Al. .............
plumbing in the buildings of . . /W.,— ...................
at . :,� (/ 0 LA - I'll f Irl? ( ( L
............................... I .... North Andover, Mass.
Fee. Lic. No. /�� 7 ?
...... ....
POMBING INSPECTOR
Check # '/
WHITE: Applicant CANARY: Building Dept PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print) Lt7 21)
NORTHANDOVER . , MASSACHUSETTS Date
Building Location;Z/) Owners Name Permit
Amount,
Type of Occupancy
New Renovation Replacement Plans Submitted Yes No
(Print or type) Check one: Certificate
Installing Company Name z� /L/ Corp.
Address FiPartner.
Business Telephone Finn/Co.
Name ofLicensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy R1 Other type of indemmnity Bond F]
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 -4
Signature Owner F1 , Agent r-1
I hereby certify that all of the details and informafion I have submitted (or entered) in above application are true and accurate to the
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 Massachusett.-j( Ska�e Plumbing �pdefj ChaPer 142 of the General Laws.
Av-
Title
City/Town
APPROVED (OFFICE USE ONLY
Type of Plumbing License
Master
Number Er Journeyman