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4` TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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This certifies that ... .................
has permission for gas installation .. ,�!� ....................
in the buildings of ..� . �. !� .... ��' ��. . ✓; :. ?..' !.?` ...... .
at�?� ...... , North Andover, Mass.
Fee..,�1 ... Lic. No.. ........
GAS INSPECTOR
Check #
3T 6
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date 7 6 L) 49
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Owner's Name
New ❑ Renovation ❑ Replacement
Permit # 3 2 66
4,,;- �70,,—n,,-.-t 107 -7C -
Plans Submitted ❑
Name or l z c -1 J / e e �¢—� G�" one: Certificate Installing Company
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Address s " /� 1) X- {y Z,
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Name of Licensed Plumber or Gas Fitter
❑ Partner.
[3-Firm/Co
40— 61"t 4L(—
INSURANCE
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INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 0 Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe
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 instaljati erfo ed under Per"it Issued "s applicati will be in
compliance with all pertinent provisions of the Massach efts State C9de end ChalOr 142 of a General
(Title
City/Town
VED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber
Gas Fitter LicenseP
Journeyman
Is
ANDOVER CHIMNEYS DATE
640 South Union Street
LAWRENCE. MA 01843 NUMBER
(978) 683-5139
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TERMS: J ✓ -
PLEASE DETACH AND RETURN WITH YOUR REMITTANCE
DATE CHARGES AND CREDITS BALAN(
BALANCE FORWARD
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ANDOVER CHIMNEYS C� PIN HIS COLUMN
IN THIS COLUMN