HomeMy WebLinkAboutMiscellaneous - 33 BUCKINGHAM ROAD 4/30/2018N
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o TOWN OF NORTH ANDOVERa
}y ; , PERMIT FORGASINSTALLATION �a,
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` This certifies thats.. `�. !... / .-� ... ... .. .
has permission for gas installation . S?�.0 U C' ..............
in the buildings of C ..
at North Andover, Mass..
Fee. Z!� Lic. No. .$. v('. .
VAS INSPECT
Check # 1 a
6561
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MASSACHUSETTS UNwoRM APPUCATON FOR PERMIT TO DO GAS EIT'I'IlVG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS date 7,1d dF
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Building Locations
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Owner's Name
New ❑ Renovation Replacement IT
Permit #��
S- Amounts-,,
Plans Submitted ❑
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U B-BASEM ENT
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TH..FLOOR
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(Print or type) , Q
Name 1/� �J
Address
usmess a en one e _
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Name of Licensed Plumber'or Gas Fitter
INSURANCE COVERAGE
44 f
Check one: Certificate Installing Company
Corp.
Partner.
I...J Firm/Co.
I have a current liability Insurance policy or it's substantial equivalent Check one:
If you have checked Yes, please indicate the type coverage by checking the appropriate box Yes
Not
Liability insurance policy ED -Other type of indemnity
ED I Bond 13
Owner's insurance Waiver: I am aware that the licensee does_ no_ t_h� 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:
Owner 13 Agent 13
1 hereby certify that all of the details and information I have submitted (or entered) in above applicationare true and accurate to the
best of my knowledge and that all plumbing work and installations erformed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts t Gas g4de and Chanter 142 of the Gen al L
By:
Title
City/Town,
APPROVED (OFFICE USE ONLY)
Gene—
Signature of Licensed Plu er Or Gas Fitter
Plumber
Gas Fitter Icense um er LMaster
0 Journeyman
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