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Date .. !�/ . ?...� —C. ? ....
` TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .. �.r'r. ...i. �..`..
........................
has permission for gas installation �1) 1'. Y.I:% I . . . . . . . . . . . . . . . . .
in the buildings of .. S!� !`/.� G ............................
at .. !. . .?. ......... r North Andover, Mass.
Fee. 3. Lic. No../. /.�...! . `!! (.�
GASINSPECTOR
Check # 7 t
4355
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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Mass. Date p
'� d k9' ��Per(�m%%it #
Building Location�� Owner's NamegJ/Jr !..
Type of Occupancy / 'Tdf%�j/e
New ❑ Renovation ❑ Replacement V Plans Submitted: Yes❑ No
Installing Company Name} 9' -- �
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Check one: Certificate
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Installing Company Name} 9' -- �
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Check one: Certificate
Address ; W t cz),L1
Corporation
tA 0 �1 �. s n t -f ( _1, �,}
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❑
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Business Telephone �;C :
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Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
have a curre t liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
A Jdbliity insurance policy ❑ 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 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of C,vner or Owner's Agent Owner❑ Agent ❑
I hereby certify that all of the details and In
I have submiited for entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will,be in compliance with all
pertinent provisions of the Massachusetts State Gas Cede and Chapter 142 o e General Laws.
Cat"
By__ -
Y _ T e of License: M�—�
Plumber ature of Licensed Plumber or Gas Fitter
Title Gastef
faster �.cense Number /
City/Town LJ Journeyman
APPROVED (OFFICE USE ONLYI
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i�� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Mass. Date_ �- `., _1 ri f Permit # Z.1 7
Building Location OWner'S Name
Type of Occupancy .
G
New ❑ Renovation ❑ Replacement Plans Submitted: Yes[] No p
Installing Company N
Addre.-
Business T
�-A.�]Gj
Name of Licensed Plumber or Gas Filter
Check one:
Q3pj8—` ' ❑ Corporation
❑� /Partnership
- / [K' Firm/Co.
�m�4S 1 OZI)oA /i -4 L -
Certificate #
INSURANCE COVE AGE:
I have a curre t Illty Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ .
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy t7YY/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 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent ❑
Signature of Owner or Owners 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 Iliapermit Issued for this application will be In compliance with all
pertinent provisions of the Massachusetts Slate Gas Code and Chapter 142 of the Ge I Laws. nn
T;�Ga7s
oLUcense: V __
umber nature o ce um er or Gas Ater
Title Iilloraster Ucense Number �City/Town. ourneyman
V'i'tKNf 7(OFFIC 019.
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Installing Company N
Addre.-
Business T
�-A.�]Gj
Name of Licensed Plumber or Gas Filter
Check one:
Q3pj8—` ' ❑ Corporation
❑� /Partnership
- / [K' Firm/Co.
�m�4S 1 OZI)oA /i -4 L -
Certificate #
INSURANCE COVE AGE:
I have a curre t Illty Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ .
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy t7YY/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 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent ❑
Signature of Owner or Owners 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 Iliapermit Issued for this application will be In compliance with all
pertinent provisions of the Massachusetts Slate Gas Code and Chapter 142 of the Ge I Laws. nn
T;�Ga7s
oLUcense: V __
umber nature o ce um er or Gas Ater
Title Iilloraster Ucense Number �City/Town. ourneyman
V'i'tKNf 7(OFFIC 019.
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�Ta27 Date.
NORTH TOWN OF NORTH ANDOVER.
0_ � ap PERMIT FOR GAS INSTALLATION
�1SSACFHUSE� 5 ..
This certifies that .. .�.. -�' c?!� we. L.L s .
has permission for gas installation..A, :E
in the buildings of 1!t-,�I !'! r!9 ... r�? e, .... ; .
at .%���+.�.�..? ?........... , North Andover, Mass.
Fee. +. .. W929*ti4:�4 . • . • •..... .
0025.
PINSPECT�'
WHITE: Applicant CANARY: Building Dept.' PINK: Treasurer GOLD: File