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TOWN OF NORTH ANDOVER
41 PERMIT FOR GAS INSTALLATIO
This certifies that . . U- 14 /�/) ... //!�� ... / /,I. � � /"- /' . . . .
has permission for gas installation .�� ....................
in the buildings of .....................
at ............. North Andover, Mass.
Fee Lic. No..4.1).
,/GAS INSPECTOR
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Date a3
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Building Permit # -1"" L130 t
Location l,'-,
Owner's 1�2
Name
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New Renovation 0 Replacement lil/ Plans Submitted: Yes 0 No o
3
Buildina Permit No
Check one:
Installing Company Name WATER-HFATFR iNsTALLri-R8 ecorp.
Address 14 DARTMOUTH STREET 0 Partnership
WUMEN, MA 02148 [1 Firm/Co.
Business Telephone ZZI
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE: Check
I have a current liability insurance policy or its substantial equivalent. Yes �7 N o ci
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy El"" Other type of indemnity El Bond []
Certificate
A3,09
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:
Owne r ci Agent [3
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in the above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
Type of License:
Fee 0 Plumber �z oh�r—
[] Gasfitter S
Check # Signa e of Licen ed Plumbeir/or Gas Fitter
iEr . Master
Date 17— Journeyman License Number Y/51/
APPROVED (Office Use Only)
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SUB-BSMT.
BASEMENT
I ST FLOOR
2ND FLOOR
3 RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Check one:
Installing Company Name WATER-HFATFR iNsTALLri-R8 ecorp.
Address 14 DARTMOUTH STREET 0 Partnership
WUMEN, MA 02148 [1 Firm/Co.
Business Telephone ZZI
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE: Check
I have a current liability insurance policy or its substantial equivalent. Yes �7 N o ci
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy El"" Other type of indemnity El Bond []
Certificate
A3,09
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:
Owne r ci Agent [3
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in the above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
Type of License:
Fee 0 Plumber �z oh�r—
[] Gasfitter S
Check # Signa e of Licen ed Plumbeir/or Gas Fitter
iEr . Master
Date 17— Journeyman License Number Y/51/
APPROVED (Office Use Only)
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