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TOWN OF NORTH ANDOVER
V,
PERMIT FOR GAS INSTALLATION
This certi f ies t.hat ..........
has permission for gas installation ............
in the buildings of. .........................
at ........ North Andover, Mass.
Fee-_.�5 ..... L:ic. No..
AS IN CTO
R
Check #
6567
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINGG
Ir e)
S- A. Da 20 Permit I
tocas
Ovirners-ft
2M�Me
�fl W W E,4
Type of a ccupancy
Newo Renovation 0
installing Company
Plans Submitted: Yes 0 No 0
Business Telephone 7--!!!5
Name,bf Licensed Plumber, or G as Fitter
Check one: Certificate
corporation
0 Partnership
"'Vrrm/Co.
INSURANCE COVERAGE:
I have a curren bility Insurance policy or its substantial equivalent which meets the requirements of MGL CrL 142.
Yes 0/!P No 0
If you have Checked Yes, please indicate the type of coverage by checking the 2ppropriate box.
other type bf Indemnity 0 Bond 0
A liability Insurance policy
OVVNEIVS INSURNACE 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 sig inature on this permit leation vkalves this requirement
Check one:
Sianature of Owner or owners Agent Owner 0 Agent D
1 hereby certify that all of the details and Information f have subrrdtted (or entered) In above application are true and accurate to the best of
my knovAedge and that 211 plumbing work and installations performed under the s ued for this applic2tio 11 be In complia ce vA tji
s
p: tr
all pertinent provisions of the Massachusetts Statecas.tode andChapterl42 of the7l-ne-)
T e 6- da ;Z'
yp f License:
Plumber Qature of LicensedPib'ghitb42'�e�-rljoFG2-.—Fi—tte�r
By OG
Tit1c Wgtter
City/Town License Number q4:5 L
APPROVED (OFFICE 0.1ourneyman
vim
Mom
No
Business Telephone 7--!!!5
Name,bf Licensed Plumber, or G as Fitter
Check one: Certificate
corporation
0 Partnership
"'Vrrm/Co.
INSURANCE COVERAGE:
I have a curren bility Insurance policy or its substantial equivalent which meets the requirements of MGL CrL 142.
Yes 0/!P No 0
If you have Checked Yes, please indicate the type of coverage by checking the 2ppropriate box.
other type bf Indemnity 0 Bond 0
A liability Insurance policy
OVVNEIVS INSURNACE 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 sig inature on this permit leation vkalves this requirement
Check one:
Sianature of Owner or owners Agent Owner 0 Agent D
1 hereby certify that all of the details and Information f have subrrdtted (or entered) In above application are true and accurate to the best of
my knovAedge and that 211 plumbing work and installations performed under the s ued for this applic2tio 11 be In complia ce vA tji
s
p: tr
all pertinent provisions of the Massachusetts Statecas.tode andChapterl42 of the7l-ne-)
T e 6- da ;Z'
yp f License:
Plumber Qature of LicensedPib'ghitb42'�e�-rljoFG2-.—Fi—tte�r
By OG
Tit1c Wgtter
City/Town License Number q4:5 L
APPROVED (OFFICE 0.1ourneyman