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TOW OF Afi NDOVER
o— PERMIT FOR GAS INSTALLATION
This certifies that ...... cQ...... .
has permission for gas installation ... - : � --•-P'
in the buildings of ..C.:� ��. `...................... ..... .
at .`�J ) ......... .. ... , North Andover, Mass.
Fee. Lic. No... r�-..........
GAS INSPECTOR
Check # ';�W
�45�
MASSACHUSETTS UNIFORM APPLICATON FOR PERMTF TO DO GAS FITTING
(Type or print) Date All, 7
NORTH ANDOVER, MASSACHUSETTS
ASSJA/CHUSETTS� /� �n
g 33 U )t li L-4 c� e ! 9 f� 1? en I //C , Permit
Building Locations
v�
Owner's Name Amount $
New D Renovation D Replacement Plans Submitted D
(Print or type)
Name
Address !� /� 1r1c,i� r/� /%i SLC✓( I'Yi,'� D) �i�iy
Check one: Certificate Installing Company
ElCorp.
ElPartner.
Business Telephone _ Firm/Co.
Name of Licensed Plumber or Gas Fitter / G r^ -
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ Noo
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy [a Other type of indemnity D Bond
Owner's Insurance Waiver: 1 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 cernty that allot the details and information I have submitted (ore ered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perf under Permi ssued for this application will be in
compliance with all pertinent provisions of the Massachusetts State as ode and ChaptgVIA of thea eneral Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of L
Plumber
Gas Fitter
❑ Master
Journeyman
Ked Plumber Or Witter
613)
Icense Number
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SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type)
Name
Address !� /� 1r1c,i� r/� /%i SLC✓( I'Yi,'� D) �i�iy
Check one: Certificate Installing Company
ElCorp.
ElPartner.
Business Telephone _ Firm/Co.
Name of Licensed Plumber or Gas Fitter / G r^ -
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ Noo
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy [a Other type of indemnity D Bond
Owner's Insurance Waiver: 1 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 cernty that allot the details and information I have submitted (ore ered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perf under Permi ssued for this application will be in
compliance with all pertinent provisions of the Massachusetts State as ode and ChaptgVIA of thea eneral Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of L
Plumber
Gas Fitter
❑ Master
Journeyman
Ked Plumber Or Witter
613)
Icense Number
%ordon Boyd & Company, Anc.
Multiple Line Adjusters & Surveyors • Established 1926
A SlinSidicry or Notional ,r71,7irr (;op,,;Co n
TELEX NO. 466111
CABLE:BOYDCO
CRESS REPLY TO:
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Building: Board of Selectmen
Town tit ) (_ fiauja Hall
addresses (
AIC, -Th %1��)orJ en. N 14 (_ V&A p9m),41mc
Re: Insured: L6 (r -
Property address: —3 3 01 )4 Q e ct:R -P Y\ bf, it C—
A) ()
—A)() t'T"S'1 io D6 fl �2, m L�
Policy No.. //0/1 _ '/0(/ / lL
Loss of i�S 19
File or-etaim No..
`t
Claim has been made involving loss, damage or destruction of the above captioned property, which
may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable.
If any notice under Mass Gen. Laws, Ch. 139 Sec. 313 is appropriate please direct it to the attention
of the writer and include a reference to the captioned insured, location, policy number, date of loss
and claim or file number.
On this date, I caused copies of this notice to be sent to the persons named above at the addresses
indicated above by first class mail. 31
Signature and date
r�5
CLAIMS SERVICE OF
NEW ENGLAND, INC.
b--�
MASSACHUSETTS
CONNECTICUT
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