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210/095.A-0052-0000.0
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r � WORTFr
ii TOWN OF NORTH ANDD R
t . PERMIT FOR GAS INST LATION
�,SSACHUSE�4
This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . . . . . . . . . . . .
r in the buildings of . z�'O �.4!.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
F
at .� ��`'. t j a. . .� . . . . . . . . . . . . . .. North Andover, Mass.
Fee.a. . . . . . Lic. No.. . � . . .. . . . . . �1 ."` . . . . . . . .
E G S INSPECTOR
Check# ) Z
5673
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Mass. Date ]w elS 20u(— Permit# S~6 ?3
t"
Building Location Owner's Name `
Owner Tel# -2 / S Type of Occupancy `G s
New M Renovation ❑ Replacement ❑ Plan Submitted: Yes ❑ No ❑
FIXTURES
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SUB-BSMT
BASEMENT
i
IST FLOOR
>i
2"D FLOOR
3RD FLOOR
4T"FLOOR
5T"FLOOR
6T"FLOOR
7"FLOOR
8T"FLOOR
Installing Company Name �, 'J� / Check one: Certificate
Address Corporation
❑Partnership
Business Telephone# % 7 �— �`��'� 7 7 irmlCo.
Name of Licensed Plumber or Gas Fitters 42'r—
INSURANCE COVERAGE:
I have a current liability insurance policy cits substantia!equivalent which meets the requirerbts of MGL Ch.142
Yes B-/ No ❑
If.you have checked yes,please indicate the type coverage by checking the appropriate box.
A liability insurance policy a/ 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
1 hereby certify that all of the details and information 1 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 the permit issued for this application mpliance with all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge s.
By Type of License:
e'Plumber. Signa ure of Licensed Plumber or as Fitter
Title ❑Gas fitter /�F
ster License Numb
r3-M1� er
City/Town o Journeyman
APPROVED(OFFICE USE ONLY)