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} 40RT#1 TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
�9SSACHUSES
This certifies that_.-. ��—`"�:`"`�`- . . . . . . . . . . . . . .
has permission for gas installation . . .�`
ii: the buildings of . . . .!. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at & . .•/. , North Andover, Mass.
FeerS
. . . . . . Lic. No:�/.
n G� GAS IILISPE/C�TOR
WHITE::Applicant CANARY: Building Dept. PINK:Treasurer
Y MASSA Tl APP CATON FOR PERMIT TO DO GAS ffrMG
I Type or print) PARCEL Date Y—/0
NORTH ANDD
Building Locations ,te�' Permit#
Amount S
Owner's Name C,
New❑ Renovation ❑ Replacement 1z Plans Submitted ❑
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SU B -BASEM ENT
BASE ;M ENT
IST. FLUOR ;
2ND . FLOUR
3RD . FLOUR
4'ril . FLUOR
5'r ii . FLOUR
6T It FLOUR
7T 11 . FLUOR
>3'rN . FLOUR
(Print or type) Check one: Certificate Installing Company
Name V!C- ' ���e ❑ Corp,
Address417 /r ❑ Partner.
Business Telephone ? G ('�J ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter f)-G s,�J W t S Sy S t
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑
If you have checked ves,please indicate the type coverage by checking the appropriate box.
Liability insurance policy 12_.__ Other tvpe of indemnity ❑ Bond ❑
Ow�Mr'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 information 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 ilassachuserts State Gas Code and Chapter 142 of the General Laws.
t Lf R;-
Bv: Signature of Licens P1u ber Or Gas
Title . E--Plumber
CityiT,7n ❑ Gas Fitter mcense Iv moor
❑ tMaster
APPROVED(OFFICEUSE ONLY) ®_ Journeyman