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MASSACHUSETTS UNIFORM APPUCATIOC d1 JA I `��� � � GASFiTTING
(Print or Type)
NORTH ANDOVER Mass_
tuilding Location �3 ���/il _ _ it # 3
Owners Namelk/1,
New ' 7 Renovation II Replacement ID, Plans Submitted II
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(Print or Type)
Installing Company Name
Address Q�>C
6 2-�-- S�
/Check one: Certificate
Corp,
Partner.
Firm/ Co.
Business Telephone:
Name of Licensed .Plumber
or .Cas Fitter_
Insurancr- Coverage:
Indicate
the tyre of insurance coverage by checking the
appropriate -.box:
.
Liability --insurance _policy.
Other type of
indemnity..=,:.Bond_.
Insurance Waiver: I,
the
undersigned, have
been made aware that. -the licensee.of
this application -does
not have .any one o; the
above .three insurance._coverages,__.
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(Print or Type)
Installing Company Name
Address Q�>C
6 2-�-- S�
/Check one: Certificate
Corp,
Partner.
Firm/ Co.
Business Telephone:
Name of Licensed .Plumber
or .Cas Fitter_
Insurancr- Coverage:
Indicate
the tyre of insurance coverage by checking the
appropriate -.box:
.
Liability --insurance _policy.
Other type of
indemnity..=,:.Bond_.
Insurance Waiver: I,
the
undersigned, have
been made aware that. -the licensee.of
this application -does
not have .any one o; the
above .three insurance._coverages,__.
Signature of owner/agent of property Owner -Agent - -
I hczchy certify thst 111 of the devils and information, I have submitted (or e-%tered) in aba" application are trae u%d accurate to the best of my
icn0-1cd;e and that ati ptumbin; work and In tai4tioos ;czfar=c: unG4'P_`rr-.it i:.- zd rot this application will be iii compa=re with a peranat
ptorisionl of the itaruQLUsCtta State CA$ Code And C%aptcr 14Z C.f :::6a Ccieai LAW&. '
L PjGasffitt_ez
u.T�er � .
Ti..Ie Sign ure of Licensestet Plumb - or Gasfitter
C=ty/Tcwn: urneyman03
APPROVED (OFFICE USE ONLY1 License Ntunber
MASSACHUSETTS UNIFORM APPI_.ICATION FOR PERMIT TO DO GASFITTI'
(Print or Type) CC`` t
NORTH ANDOVER Mass_ Date 1,23
Building Location 3 ���/a-� �.�%f �/� Permit #
Owners Namelyl, ��¢� �� i ell
New .77, Renovation Replacement Mans Submitted n
(Print or Type) _
Installing Company NameL
Address � aL)/_ PO t-- --
" e
oz F�y l—
Check one: Certificate
�!� Q Corp.
Partner.
Firm/Co.
Business Telephone: W '6 8-`Z_ `
Name of Licensed Plumber or .Cas Fitter
Insurance Coverage: Indica:_ 6,e type of insurance coverage by checking the
appropriate.. box:_.-
Liability_..insurance .policyCL; er type o; indemnity_=.._6ond
Insurance Waiver: -I, the urdersicrie4, have been made aware that.the licensee of
this application. does not have any one of the above .three insurance.__ coverages.
Signature of owner/agent of proper -y Owner Agent
I hctcby cc:tXy that all of the deans and information I have submitted (or e=ntered) in &t=ore aoriiation ate true ar.d accurate to the best of my
k.'to-tcd;e and ticat aU plumbing rock and lnttallstioncs :cr•'atast; undo fo=T.it i= d fo: this sprdcxtion riu be Int compliance with —,crus=t
provisions of the WA&&2CtiuxttZ Slate Cas Cade and C%aptcr 14: L: o i„eae i Lars.
By '^':'?= LICENSE `
P1 L'.TL6 e r ///f
Title I GasLitter 1/ sign are of License<
plt:mb r or Gasfitter
City/Torn:Journeyman
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APPROVED (OFFICE Use Ott LY) License Number
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(Print or Type) _
Installing Company NameL
Address � aL)/_ PO t-- --
" e
oz F�y l—
Check one: Certificate
�!� Q Corp.
Partner.
Firm/Co.
Business Telephone: W '6 8-`Z_ `
Name of Licensed Plumber or .Cas Fitter
Insurance Coverage: Indica:_ 6,e type of insurance coverage by checking the
appropriate.. box:_.-
Liability_..insurance .policyCL; er type o; indemnity_=.._6ond
Insurance Waiver: -I, the urdersicrie4, have been made aware that.the licensee of
this application. does not have any one of the above .three insurance.__ coverages.
Signature of owner/agent of proper -y Owner Agent
I hctcby cc:tXy that all of the deans and information I have submitted (or e=ntered) in &t=ore aoriiation ate true ar.d accurate to the best of my
k.'to-tcd;e and ticat aU plumbing rock and lnttallstioncs :cr•'atast; undo fo=T.it i= d fo: this sprdcxtion riu be Int compliance with —,crus=t
provisions of the WA&&2CtiuxttZ Slate Cas Cade and C%aptcr 14: L: o i„eae i Lars.
By '^':'?= LICENSE `
P1 L'.TL6 e r ///f
Title I GasLitter 1/ sign are of License<
plt:mb r or Gasfitter
City/Torn:Journeyman
\�3 iv
APPROVED (OFFICE Use Ott LY) License Number
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S..'_`_`' ,.'t"'eih,We.i*'ti`'° . '.'�ti"^;,'ie:^;cru#'—•^i.'�'�M^'..._
Date . . .
NpRTH
pf TOWN OF NORTH ANDOVER A
s,ao ^,tip � - � _ Q
" PERMIT FOR .GAS INSTALLATION a
0 0 $
This certifies that ....... ...... ... .. �.;
has permission for gas installation ..�� ...............
in the buildings of
at 3.1....
...................
Fee/.)—(." 0Lic. No. .. ....... ...
• GAS INSPECTOR '
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
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