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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
SS CHU
This certifies that
has permission for gas installation--l-e—.-::�4 �. ..............
in the buildings of .... .....................
at North Andover, Mass.
Fee ..... Lic. No.. .........
���:-GAS'IN�E';AD�R
Check# e�l
6566
MASSACHUSE M UNIFORMAPPUCkTONFORPUMTO DO GAS MING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Loqations 2
Owner's Name
New Renovation Replacement 13 -
Date
Permit #
Amount $ 0 110
Plans Submitted
(Print or type)
Name �-T(
Address )57DY 1::�d W--
. Vi -,VA L9 tj
Business Tejennone /"I- �, — I --;k
Name ofLicensed Plumber�or Gas Fitter
W
Check one: Certificate Installing Company
10* Corp.
0—partner.
tj-Fi—rin/Co.
400 _-e
INSU NCE COVEPAGE
I have[� Check one:
e .
c
Ilf 'urrent liability insurance, policy or it's substantial equivalent Yes NoCj
Ybo,u have,,! checked Yes, please indicate the type coverage by checking the appropriate box.
Lia ilit
y insurance policy Other type of indemnity ID Bond 13
Owner's Insurance Waiver 1 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.
Signature of Owner or Owner's Agent Check one:
I hereby certify that all of the details and information I have submitte Owner 13 Agent 13
(or entered) in ove application are true and accurate to the
best of my knowledge and that all plumbing work and installatonfi Performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachus"e.2�de�and Ch er 142 o4the Ge e -I I
: f ant
By:
Title
City/TOwn,
APPROV, ED (OFFICE USE ONLY)
. Signature of Licensed Prumber Or Gas Fie
[3,plumber
[3 Gas Fitt �M? �=
er License N'Urnbdr-
19-Master
0 JOurneyrnan
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(Print or type)
Name �-T(
Address )57DY 1::�d W--
. Vi -,VA L9 tj
Business Tejennone /"I- �, — I --;k
Name ofLicensed Plumber�or Gas Fitter
W
Check one: Certificate Installing Company
10* Corp.
0—partner.
tj-Fi—rin/Co.
400 _-e
INSU NCE COVEPAGE
I have[� Check one:
e .
c
Ilf 'urrent liability insurance, policy or it's substantial equivalent Yes NoCj
Ybo,u have,,! checked Yes, please indicate the type coverage by checking the appropriate box.
Lia ilit
y insurance policy Other type of indemnity ID Bond 13
Owner's Insurance Waiver 1 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.
Signature of Owner or Owner's Agent Check one:
I hereby certify that all of the details and information I have submitte Owner 13 Agent 13
(or entered) in ove application are true and accurate to the
best of my knowledge and that all plumbing work and installatonfi Performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachus"e.2�de�and Ch er 142 o4the Ge e -I I
: f ant
By:
Title
City/TOwn,
APPROV, ED (OFFICE USE ONLY)
. Signature of Licensed Prumber Or Gas Fie
[3,plumber
[3 Gas Fitt �M? �=
er License N'Urnbdr-
19-Master
0 JOurneyrnan